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Full text of "The American journal of the medical sciences"

Property of the 

Lancaster City and County 
Medical Society 



No 



I 



V 



n 



ii 
ii 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, 

FELLOW OF THK PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION; OF THE AMERICAN PHILOSOPHICAL SOCIETY) OF THE 
ACADEMY OP NATURAL SCIENCES OF PHILADELPHIA, 
&C.&C.&C. 



NEW SERIES. 
YOL. XXX. 




PHILADELPHIA: 

BLANCHARD & LEA. 
1855. 



69456 



Entered according to the Act of Congress, in the year 1855, by 
BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States, in and for the 
Eastern District of the State of Pennsylvania. 




nilLADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



^6) READERS AND CORRESPONDENTS. 
The following works have been received : — 

Lettsomian Lectures on Insanity. By Forbes Winslow, M. D., D. C. L., &c. 
&c. London: John Churchill, 1854. (From the Author.) 

The Diagnosis of Surgical Cancer (the Listen Prize Essay for 1854). By 
John Zachariah Laurence, Surgeon to the Northern and Farringdon Dispen- 
saries, &c. London: John Churchill, 1855. (From the Author.) 

On a New Method of Treating Neuralgia by the direct application of Opiates 
to the Painful Points. By Alexander Wood, M. D., &c. &c. Edinburgh, 1855. 
(From the Author.) 

A Practical Treatise on the Diseases, Injuries, and Malformations of the 
Urinary Bladder, and Prostate Gland, and the Urethra. By S. D. Gross, M. D., 
Professor of Surgery in the University of Louisville, one of the Surgeons of the 
Louisville Marine Hospital, etc. etc. Second edition, revised and much en- 
larged, with one hundred and eighty- four illustrations. Philadelphia : Blanchard 
& Lea, 1855. (From the Publishers.) 

The Pathology and Treatment of Leucorrhoea. By W. Tyler Smith, M. D., 
Member of the Royal College of Physicians, Physician Accoucheur to St. 
Mary's Hospital, etc. etc. Philadelphia : Blanchard & Lea, 1855. (From the 
Publishers.) 

Surgical Reports and Miscellaneous Papers on Medical Subjects. By Geo. 
Hayward, M. D., President of the Massachusetts Medical Society, Fellow of the 
American Academy of Arts and Sciences, etc. Boston, 1855. (From the 
Author.) 

Transactions of the Ninth Annual Meeting of the Ohio State Medical Society, 
held in the city of Cincinnati, June 6, 1854. Cincinnati, 1854. (From Julius 
S. Taylor, M.D.) 

The Proceedings and Reports of the Medical and Chirurgical Faculty of 
Maryland. Incorporated in 1799. At its annual session in June, and special 
session in September, 1854, in the city of Baltimore. Baltimore, 1855. 

Transactions of the Medical Association of the State of Alabama, at its eighth 
annual session begun and held in the city of Mobile, February 5, 6, and 7, 
1855. Together with the Code of Medical Ethics and a list of members. (From 
the Society.) 

The Transactions of the New York Academy of Medicine, containing a Report 
on Solidified Milk by the Standing Committee on Public Health and Legal 
Medicine. New York, 1855. 

An Essay to prove the Contagious Character of Malignant Cholera, with brief 
Instructions for its Prevention and Cure. By Bernard M. Byrne, M. D., Sur- 
geon U. S. Army. Second edition, with additional notes by the author. Phila- 
delphia: Childs & Petersen, 1855. (From the Publishers.) 

An Outline of Medical Chemistry for the Use of Students. By B. Howard 
Rand, A. M., M. D., Professor of Chemistry in the Philadelphia College of 
Medicine, etc. Philadelphia: Lindsay & Blakiston, 1855. (From the Pub- 
lishers.) 

A Monograph on Mental Unsoundness. By Francis Wharton. Philadel- 
phia: Kay & Brother, 1855. (From the Author.) 

Cases of Polypus of the Womb, with remarks. By Walter Channing, 
M. D. Republished from the Boston Medical and Surgical Journal. Boston, 
1855. (From the Author.) 

On the Chemical Analysis of the Tennessee Collection of Urinary Calculi. 
By E. B. Haskins, M. D. Clarksville, 1855. 



4 



TO READERS AND CORRESPONDENTS. 



Discovery of the Cause, Nature, Cure, and Prevention of Epidemic Cholera. 
By M. L. Knapp, M. D., late Professor of Materia Medica, and President of the 
College of Physicians and Surgeons of the University of Iowa, etc. etc. New 
York, 1855. (From the Author.) 

Theories of the Production of Males and Females. By Silas Hubbard, M. D. 
(From the Author.) 

Experimental and Clinical Researches on the Physiology and Pathology of 
the Spinal Cord, and some other parts of the Nervous Centres. By E. Brown- 
Sequard, M. D., of Paris, Professor of the Institutes of Medicine and of Medical 
Jurisprudence in the Medical College of Virginia, etc. Richmond, 1855. (From 
the Author.) 

Case of Penetrating Gunshot Wound of the Heart : Life Protracted for Eleven 
Days. Bullet found embedded and encysted in the substance of the heart. By 
J. M. Carnochan, M. D., Surgeon in Chief to the State Hospital, etc. New 
York, ] 855. (From the Author.) 

Observations on Yellow Fever and its Relations to Quarantine and other 
Hygienic Measures. By S. L. Grier, M. D. New Orleans, 1855. 

Report of John E. Ward, Mayor of the city of Savannah. Savannah, 1855. 
(From Dr. R. D. Arnold.) 

Ectopia Cordis or Cardiac Displacement. An address read before the Suflfolk 
District Medical Society, Boston, December 30, 1854. By Buckminster Brown, 
M. D. Boston, 1855. (From the Author.) 

Improved Forceps for Hare-Lip Operation, and Fatal Result of an Operation 
for the Removal of a Tumour from the Neck. By Alden March, M. D. (From 
the Author.) 

On Adipocire and its Formation. By Charles M, Wetherill, Ph. D., M. D. 
Read January 19, 1855. Extracted from the Transactions of the American 
Philosophical Society, Vol. XI. Philadelphia, 1855. (From the Author.) 

Portrait of Austin Flint, M.D., editor of the Buffalo Medical Journal from 
1845 to 1855. Published by his friends of the city of Buffalo. (From the 
Publishers.) 

A Lecture on the Effects of Alcoholic Drinks on the Human System, and the 
Duties of Medical Men in relation thereto. Delivered in the Lecture-room of 
the Rush Medical College on Christmas day, 1854. By N. S. Davis, M, D., 
Professor of Pathology, Practice of Medicine, and Clinical Medicine. Chicago, 
1855. (From the Author.) 

An Address, delivered at the First Medical Commencement of the Massachu- 
setts Medical College, March 7, 1855. By D. Humphrets Storer, M. D., Pro- 
fessor of Obstetrics and Medical Jurisprudence. Boston, 1855. (From the 
Author.) 

Introductory Lecture to the Class of 1855 of the Medical Department of the 
University of Missouri. By John R. Allen, M. D., Professor of Obstetrics and 
Diseases of Women and Children. And the Valedictory Address to the Gradu- 
ates. By Pavton Spence, M. D., Professor of Physiology and Comparative 
Anatomy. Published by the Class. St. Lous, 1855. 

Needs, Duties, and Privileges of the Medical Profession. By John M'Call, 
M.D., Utica, N. Y. Read before the New York State Medical Society at its 
Annual Meeting in the city of Albany, February, 1855. 

Statistics of Injuries of the Heart. Observations on Wounds of the Heart 
and their Relations to Forensic Medicine, with a table of forty-two recorded 
cases. By Samuel S. Purple, M.D. New York: S. S. & W. Wood, 1855. 
(From the Author.) 

Annual Announcement and Catalogue of the Medical Department of the 
University of Nashville. Sessions 1855-'56. Nashville, 1855. 

University of New York, Medical Department. Annual Announcement of 
Lectures. Session 1855-'56. With catalogues of the class of 1854-^55, and 
of the Graduates of the College. New York, 1855. 

Annual Reports of the Officers of the New Jersey State Lunatic Asylum at 
Trenton for the Years 1852 and 1854. Trenton, 1853 and 1855. (From H. A. 
Buttolph, M. D.) 

Thirty-Eighth Annual Report of the State of the Asylum for the Relief of 



TO READERS AND CORRESPONDENTS. 



5 



Persons Deprived of the Use of their Reason. Philadelphia, 1855. (From Dr. 
Worthington.) 

Second Annual Report of the Trustees of the Michigan State Asylum for 
Insane, and for the Deaf and Dumb and Blind, for the Years 1853 and 1854. 
Lansing, 1855. 

Annual Report of the Trustees of the State Library of the State of New York. 
Transmitted to the Legislature March 1, 1855. Albany, 1855. (From Dr. T. 
R. Beck.) 

Eighth Annual Report of the Regents of the University of the State of New- 
York on the condition of the State Cabinet of Natural History, and of the His- 
torical and Antiquarian Collection annexed thereto. Made to the Senate Jan. 
15, 1855. Albany, 1855. (From Dr. T. R. Beck.) 

The following Journals have been received in exchange: — 

Archives d'Ophthalmologie. Par M. A. Jamain. November, December, 
1854. 

Revue de Therapeutique Medico-Chirurgicale. Par A. Martin-Lauzer, 
Jan., Feb., IMarch, April, 1855. 

Annales Medico-Psychologiques. Par MM.les Docteurs Baillarger, Cerise, 
et Moreau. Jan., 1855 

Le Moniteur des Hopitaux. Par M. H. De Castelnau. March, April, 1855. 

Gazette Medicale de Paris. March, 1855. 

Medical Times and Gazette. March, April, 1855. 

Dublin Medical Press. March, April, 1855. 

The Dublin Hospital Gazette. March, April, 1855. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. April, 1855. 

The Glasgow Medical Journal. April, 1855. 

Monthly Journal of Medicine. March, April, May, 1855. 

The Edinburgh Medical and Surgical Journal. April, 1855. 

The British and Foreign Medico-Chirurgical Review. April, 1855. 

Association Medical Journal. Edited by John Rose Cormack. Blarch, 
April, May, 1855. 

The Dublin Quarterly Journal of Medical Science. May, 1855. 

The Medical Chronicle or Montreal Monthly Journal of Medicine and Sur- 
gery. Edited by William Wright, M. D., and D. C. McCallum, M. D. April, 
May, June, 1855. 

Southern Medical and Surgical Journal. Edited by L. A. Dugas, M. D., and 
Henrv Rossignol, M. D. February, April, May, June, 1855. 

New York Dental Recorder. Edited by Charles W. Baillard, D. D. S. 
March, April, 1855. 

Memphis Medical Recorder. Edited by A. P. Merrill, M. D. March, May, 
1855. 

Iowa Medical Journal. Conducted by the Faculty of the Iowa University. 
February, March, April, May, 1855. 

The Medical Examiner. Edited by Samuel L. Hollingsworth, M.D. April, 
May, June, 1855. 

The American Journal of Insanity. Edited by the Of&cers of the New York 
State Lunatic Asylum. April, 1855. 

The American Medical Gazette. Edited by D. M. Reese, M.D. April, May, 
June, 1855, 

The Western Journal of Medicine and Surgery. Edited by Ltjnsford P. 
Yandell, M. D. March, April, 1855. 

The Boston Medical and Surgical Journal. Edited by Drs. Smith, Morland, 
and MiNOT. April, May, June, 1855. 

The American Medical Monthly. Edited by Edward II. Parker, M.D. 
April, May, June, 1855. 

Buffalo Medical Journal. Edited by Austin Flint, M. D., and Sanford B. 
Hunt, M.D. April, May, June, 1855, 



6 



TO READERS AND CORRESPONDENTS. 



The Stethoscope. Edited by Drs. Atkinson, Haxall, Boltin, Lewis, Mer- 
RiTT, and Wilson. April, May, June, 1855. 

The Western Lancet. Edited by T. Wood, M.D. April, May, 1855. 

New York Medical Times. Edited by H. D. Bulkley, M. D., and J. G. 
Adams, M. D, April, May, June, 1855. 

The Peninsular Journal of Medicine. Edited by A. B. Palmer, M. D., and 
E. Andrews, M. D. April, May, June, 1855. 

The Virginia Medical and Surgical J ournal. Edited by Drs. McCaw, Peebles, 
and Otis. April, May, June, 1855. 

The New Jersey Medical Reporter. Edited by S. W. Butler, M. D. April, 
May, June, 1855. 

The New Hampshire Journal of Medicine. Edited by George H. Hubbard, 
M.D. April, May, June, 1855. 

The American Journal of Dental Science. Edited by Chapin A. Harris, 
M. D., D. D. S., and A. Snowden Piggot, M. D. April, 1855. 

The North Western Medical and Surgical Journal. Edited by N. S. Dayis, 
M.D., and H. A. Johnson, M. D. April, May, June, 1855. 

Nashville Journal of Medicine and Surgery. Edited by W. K. Bowling, M. D., 
and Paul F. Eye, M.D. April, May, June, 1855. 

The Medical Counsellor. Edited by R. Hills, M.D. April, May, June, 
1855. 

New Orleans Medical News and Hospital Gazette. Edited by Drs. Choppin, 
Beard, and Vance. April, May, June, 1855. 

The Medical Reporter. Published under the direction of the Chester and 
Delaware County Medical Societies. January, April, 1855. 

American Journal of Pharmacy. Edited by Wji. Procter, Jr. May, 1855. 

The New York Journal of Medicine and the Collateral Sciences. Edited by 
Samuel Purple, M.D., and Stephen Smith, M.D. May, 1855. 

Charleston Medical Journal. Edited by C. Happoldt, M.D., assisted by 
D. J. Cain, M. D., and F. Peyre Porcher, M. D. May, 1855. 

The Ohio Medical and Surgical Journal. Edited by John Dawson, M. D. 
May, 1855. 

The American Journal of Science and Arts. Conducted by Professors B. 
SiLLiMAN, B. Silliman, Jr., and J. D. Dana, in connection with Professors Gray 
and Agassiz, and Dr. Gibbs. May, 1855. 

The New Orleans Medical and Surgical J ournal. Edited by Bennet Dowler, 
M. D. May, 1855. 

St. Louis Medical and Surgical Journal. Edited by M. L. Linton, M. D., 
W. M. McPheeters, M. D., John S. Moore, M. D., and J. R. Allen, M. D. 
May, 1855. 

The Southern Journal of Medical and Physical Sciences. Edited by Drs. 
W. P. Jones, B. Wood, J. W. King, and R. 0. Currey. January, March, 1855. 



Communications intended for publication, and Books for Review, should be sent,/ree 
of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the Me- 
dical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed as 
above, and (carriage paid) under cover, to John Miller, Henrietta Street, Covent Gar- 
den, London; or M. Hector Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us 
safely and without delay. We particularly request the attention of our foreign corre- 
spondents to the above, as we are often subjected to unnecessary expense for postage 
and carriage. 

All remittances of money, and letters on the business of the Journal, should be ad- 
dressed exclusively to the publishers, Messrs. Blanchard & Lea. 

Jg^* The advertisement-sheet belongs to the business department of the Journal 
and all communications for it should be made to the publishers. 



CONTENTS 



OF THE 



AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 
NO. LVIII. NEW SERIES. 

JULY, 1855. ' 



ORIGINAL COMMUNICATIONS. 



MEMOIRS AND CASES. 

ART. PAGE 

I. Cas« of a Monstrous Birth — described in a Letter from Dr. G. W. Boerst- 
ler, of Lancaster, Ohio, to Dr. Meigs, of Philadelphia — with remarks on 
the Case. By C. D. Meigs. M. D., Professor of Midwifery, &c., in Jef- 
ferson Medical College. (With two lithograph illustrations from Da- 
guerreotypes by Root.) 13 

II. A Sketch of the Medical Topography of Fort Reading, California. By 
J. F. Hammond, M. D., Assistant Surgeon U. S. Army. (Communicated 

by Thomas Lawson, M. D., Surgeon-General U. S. A.) - - - - 21 

III. On the Physiology of Exercise. ByWm. H. Byford, M. D., of Evans- 
yille, Indiana, 32 

IV. On the Climate and Salubrity of Fort Moultrie and Sullivan's Island, 
Charleston Harbour, S. C, with Incidental Remarks on the Yellow Fever 
of the City of Charleston. By John B. Porter, M. D., Surgeon U. S. 
Army. 42 

V. Pulmonary Lesion treated as an event arising in the progress of Con- 
stitutional Decline under the Tubercular Diathesis. By J. P. Hall, M. 

D., of Glasgow, Kentucky. 50 

YI. Inquiry into the Physiology of the Organic Nervous System. By Isaac 
Casselberry, M. D., Evansville, Ind. 56 

YII. On Incontinence of Urine in Children. By D. D. Slade, M. D., of 
Boston. 71 

VIII. Three Surgical Cases. Reported by J. C. Nott, M. D., of Mobile, 
Alabama. (With a wood-cut.) 77 

IX. On the Use of the Foramen Soemmering of the Eye. By F. Leaming, 

M. D., of Tippecanoe Co., Indiana. (With two wood-cuts.) - - - 80 

X. Knife-Needle for the Operation for Cataract by Solution or Absorption. 

By Isaac Hays, M. D. - - - - - 81 

XI. A Case of Vicarious Secretion of Milk. By S. Wier Mitchell, M. D. - 83 

XII. Castration; Recovery, followed by Phthisis Pulmonalis. By Wm. 

T. Taylor, M.D. 85 



8 



CONTENTS. 



REVIEWS. 

ART. PAGE 

XIII. The Pathology and Treatment of Stricture of the Urethra, both in 
the Male and Female ; being the Treatise for which the Jacksonian 
Prize, for the year 1852, was awarded by the College of Surgeons of Eng- 
land. Bv E[enry Thompson, F. R. C. S., M. B. Lond., &c. &c. London : 
John Churchill, 1854. 8vo. pp. 424. 87 

XIV. Inquest on the Death of Agnes E. Lottimer, before Dr. George C. 
Ball, Coroner, Brooklyn, X. Y. New York, 1854. pp. 44, 8vo. - - 105 

BIBLIOGRAPHICAL NOTICES. 

XV. Transactions of American Medical Societies : — 

1. Transactions of the Ninth Annual Meeting of the Ohio State Medical 
Society, held in the City of Cincinnati, June 6, 1854. 8vo. p. 172. 

2. The Proceedings and Reports of the Medical and Chirurgical Faculty 
of Maryland, Incorporated in 1799, at its Annual Session, in June, 
and Special Session in September, 1854, in the City of Baltimore. 8vo. 
p. 82. 

3. The Transactions of the New York Academy of Medicine. Vol. i. 
Part II. Containing Hospital Hygiene Illustrated, by John H. Gris- 
cora, M.D. 8vo. pp. 12. 

The Transactions of the New York Academy of Medicine. Vol. i. Part 
III. Containing a Report on Solidified Milk, by the Standing Com- 
mittee on Public Health and Legal Medicine. 8vo. pp. 12. - - 121 

XVI. Reports of the American Institutions for the Insane. 

1. Of the New Hampshire State Asylum, for 1852 and 1853. 

2. Of the McLean Asylum, for 1853 and 1854. 

3. Of the Retreat at Hartford, for 1853. 

4. Of the Asylum for the Poor, BlackwelFs Island, N. Y. City, for 1853. 

5. Of the Indiana State Hospital, for 1853 and 1854. 

6. Of the Illinois State Hospital, biennial, for 1853-54. 

7. Of the Missouri State Asylum, biennial, for 1852-53. - - - 137 

XVII. A Practical Treatise on the Diseases, Injuries, and Malformations 
of the Urinary Bladder, the Prostate Gland, and the Urethra. By S. D. 
Gross, M. D., Prof, of Surgery in the University of Louisville, &c. &c. 
&c. Second edition, revised and much enlarged, with one hundred and 
eighty-four illustrations. Philadelphia, Blanchard & Lea, 1855. Pp. 
925, including Appendix and Index. 147 

XVIII. Surgical Reports and Miscellaneous Papers on Medical Subjects. 
By George Hayward, M. D., President of the Massachusetts Medical So- 
ciety ; Fellow of the American Academy of Arts and Sciences ; late Pro- 
fessor of Surgery in Harvard University ; and Consulting Surgeon to 
the Massachusetts General Hospital. Boston: Phillips, Sampson, & Co. 
1855. 12mo. pp. 452, including index. 149 

XIX. Difficult Labours and their Treatment. By M. B. Wright, M. D., of 
Cincinnati. For which a Gold Medal was awarded by the Ohio State 

■ Medical Society. 8vo. pp. 32. 150 

XX. Lectures in reply to the Croonian Lectures for 1854, of Charles West, 
of London, on the Pathological Importance of Ulceration of the Os Uteri. 
By Henry Miller, M. D., Professor of Obstetric Medicine in the Univer- 
sity of Louisville, etc. etc. From the Western Journal of Medicine. 
8vo. pp. 71. Louisville, Ky., 1855. 154 

XXI. On the Construction, Organization, and General Arrangements of 
Hospitals for the Insane. By Thomas S. Kirkbride, M. D., Physician to 
the Pennsylvania Hospital for the Insane. Philadelphia : Lindsay & 
Blakiston, 1854. 8vo., pp. 80. - - - - - - - -155 



CONTENTS. 



9 



ART. PAGE 

XXII. 1. The Progressive Changes which have taken place, since the time 
of Pinel, in the Moral Management of the Insane ; and the various Con- 
trivances which have been adopted instead of Mechanical Restraint. 
By Daniel H. Tuke, M. D., Assistant Medical Officer of the York Retreat, 
&c., &c. London; John Churchill, 1854. 

2. The Asylums of Holland ; their Past and Present Condition. By 
Daniel H. Tuke, M. D. From the Psychological Journal, July 1, 1854. 157 

XXIII. Experimenial and Clinical Researches on the Physiology and Pa- 
thology of the Spinal Cord, and some other parts of the Nervous Centres. 
By E. Brown-Sequard, M. D., of Paris, Professor of the Institutes of 
Medicine and of Medical Jurisprudence in the Medical College of Vir- 
ginia, etc. 8vo. pp. 66. Richmond, 1855. 161 

XXIV. Observations on Yellow Fever, and its Relations to Quarantine and 
other Hygienic Measures. By S. L. Grier, M. D. 8vo. pp.41. New 
Orleans, 1854. 165 

XXV. Illustrated Manual of Operative Surgery and Surgical Anatomy. 
By MM. C. Bernard, D.M. P., and Ch. Huette. Edited, with notes and 
additions, and adapted to the use of the American Medical Student, by 
W. H. Van Buren, M. D., Prof, of Anatomy University Medical Col- 
lege, and Surgeon to New York Hospital, and C. E. Isaacs, M. D., De- 
monstrator of Anatomy, Univ. Med. Coll., and Cod suiting Surgeon to 
the Penitentiary Hospital, Blackwell's Island. Illustrated with steel 
engravings from drawings after nature, by M. J. Leveille. Designed to 
serve as a companion to the ordinary text-books of Surgery. New York: 

H. Bailliere, 290 Broadway, 1855. 113 plates, and 513 pages. - - 168 

XXVI. The Pathology and Treatment of Leucorrhoea. By W. Tyler Smith, 
M. D., Member of the Royal College of Physicians, Physician Accou- 
cheur to St. Mary's Hospital ; Lecturer on Midwifery and the Diseases 
of Women, in St. Mary's Hospital Medical School ; Vice-President of 
the Medical Society of London; Honorary Fellow of the Obstetrical So- 
ciety of Dublin, etc. etc. 8vo. pp. 199. Philadelphia, 1855 : Blanchard 

& Lea. 170 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 
Anatomy and Physiology. 



PAGE 

1. The Entrance of the Spermato- 
zoon into the Ovum. By M. 

. Keber. 177 

2. Histology of the Retina. By 
Gegenbaur, Kolliker, Leydig, H. 
MuUer, and Virchow. - - 178 

3. Composition and Action of the 
Gastric Juice. By Drs. 0. de 
Grunewald and De Schroeder. - 178 



4. Micrological Characters 
Lymph. By M. Gubler. - 

5. Regeneration of Nerves. 
Schiff. . - . - 

6. Regeneration of Tendons. 
Boner. - . . - 

7. Structureof the Starch Granule 
By M. Martin. - - - . 



PAGE 

of 

- 180 

Ry 

- 182 

Ry 

- 183 



183 



10 

« 



CONTENTS. 



Materia Medica axd Pharmacy. 

page ; page 

8. Action of Digitalis. ByDr.H. i 13. External Use of Conia. By 
Bence Jones. - - - - 184 Murawjeff. .... igJ 

9. Source of Sarsaparilla. By : 14. External Uses of the Acid Xi- 
Dr. Berthold Seemann. - - 185 ' trate of Mercury. . - . igj 

10. Pterocarpus Erinaceus orKino- j 15. Glass Brushes for Applying 
Tree of West Africa. By Dr. I Fluid Caustics. ^ - - - 188 
Daniell. 185 J 16. Pencils of Diluted Lunar Caus- 

11. Cyanuret of Mercury. ByM. i tic. By Mr. Spencer Wells. -188 
Desmartis. _ . . _ 186 i 17. Use of Lime-Wa^er in making 

12. Modes of Exhibiting Iodine. - 186 i Bread. By Professor Liebig. - 189 



Medical Pathology and Therapeutics, and Practical Medicine. 



18. Haemoptysis as a Sign of Tu- 
bercle ; Curability of Consump- 
tion; Effect of Cod-liver Oil, &c. 189 

19. Goitre in an Infant. By Pro- 
fessor Simpson. - . - 192 

20. Peculiar Concretions in Ty- 
phus Stools. By Zimmerman. - 193 

21. Perforation of the Septum Cor- 
dis. By Prof. Hauska. - - 193 

22. On the supposed Effects of the 
suspension of accustomed Stimu- 
lants in the production of Deli- 
rium Tremens. By Dr. Peddie. 194 

23. Protracted Constipation. By 
Mr. Anderson. - - - - 196 

24. Treatment of Acute Rheuma- 
tism. ----- 198 

25. Treatment of Acute Rheuma- 
tism by Large and Frequent 
Doses of the Bi-carbonate of Pot- 
ash. By Dr. A. B. Garrod. - 198 

26. New Method of Treating Neu- 
ralgia by the direct application 
of Opiates to the Painful Points. 

By Dr. Alex. Wood. - - - 199 

27. Treatment of Cholera in the 
Stage of Collapse, by the Arti- 
ficial Production of Peritoneal 
or Cellular Dropsy. By Benj. 

W. Richardson, M.D. - -201 



28. Injectionsof Milk or Milk and 
Water into the Peritoneal Cavity 
or Cellular Tissue, or Venous 
System in Collapse of Cholera. 

By Wm. Bird Herapath, 31. D. 204 

29. Treatment of Spermatorrhoea. 

By M. Trousseau. - - - 205 

30. Gallic Acid in Pyrosis. Bv 
Dr. Bayes. . - . 206 

31. Sal Prunella in Polydipsia. 

By M. Debout. - - - - 206 

32. Pommade of Proto-Sulphate of 
Iron in the Treatment of Skin 
Diseases. By M. Devergie. - 206 

33. Employment of Alkaline Car- 
bonates in the Treatment of 
Membranous Angina. Bv M. 
March al de Calvi. - - 207 

34. Inhalations of the Fumes of 
Opium in Coryza. By Dr. Lom- 
bard. 207 

35. Chloroform for the Treatment 

of Lead Poisoning. By M.Aran. 207 

36. Iodide of Potassium for Cure 
of Lead Poisoning. By M, Mal- 
herbe. 208 

37. Employment of Wine as an 
Enema. By M. Aran. - - 208 



Surgical Pathology and Therapeutics, and Operative Surgery. 



38. Discussion on the Curability 
of Cancer, and its Diagnosis by 
means of the Microscope. By 

M. Velpeau. - - - - 209 

39. On the Formation and Exten- 
sion of Cancer-Cells in the 
Neighbourhood of Cancer, and 
their Importance in the Per- 
formance of an operation. By 
Schroeder Van Der Kolk. - 216 



i 40. Cancer -with Benign Clinical 
Features. By Dr. Robert D. 
Lyons. ----- 216 

41. Hysterical Affections of the 
Joints. By F. C. Skey, Esq. - 220 

42. Efficacy of Opium in the Cure 
of Chronic Ulcers of the Leg. 

By Mr. F. C. Skey. - - - 221 

43. Vapour of Iodine in ]Mammary 
Tumours. By M. Eichmann. - 224 



CONTENTS. 



11 



PAGE 

44. Digitalis Pommade in Hydro- 
cele. By M. Laforgue. - - 224 

45. Radical Cure of Hydrocele by 
Injections of Chloroform. By 
Prof. Langenbeck. - - - 224 

46. Two Cases of Aneurism Un- 
successfully Treated by Com- 
pression. By James Miller, 
Esq. 225 

47. Stricture of the Urethra. By 
James Syme. - 226 

48. Notes on Lithotrity, with an 
account of the results of the 
Operation in the Author's Prac- 
tice. By Sir Benjamin Brodie. 229 

49. Large Prolapsus of Eectum 
Successfully Treated with Nitric 
Acid. By Dr. Christopher Flem- 
ing. ------ 233 

50. Nitrate of Silver for the Cure 
of Prolapsus Ani. By Mr. 
Lloyd. 236 



PAGE 

51. Particular Method of Apply- 
ing Cauterization for the Re- 
union of Anomalous Fissures, 
and especially those of the Pa- 
late. By M. Cloquet. - - 236 

52. On the Employment of Tra- 
cheotomy in Croup. By M. 
Trousseau. - 237 

53. Paracentesis Thoracis. By 

M. Trousseau. - - - - 239 

54. Enormous Fibrous Tumour of 
the Neck Extirpated by the Me- 
thod of Morcellement — Reco- 
very. By M. Maisonneuve. - 239 

55. Extirpation of the Uterus. By 
Dr. Reiche. - - - - 240 

56. Excision of the Head of the 
Humerus, by a New Method. 

By M. Baudens. - - - 240 

57. Dislocation of the Astragalus 
Backwards and Inwards. By 
Prof. Williams. - - - 243 



Ophthalmology. 



58. Protrusion of the Eyeballs, 
with Enlargement of the Thy- 
roid Gland and Anaemic Palpi- 
tation. By James Begbie, M. D. 246 

59. Affection of the Heart, Thy- 
roid Gland, and Eyeballs. By 
Drs. Romberg and Henoch. - 249 

60. Change of Colour of the Iris 
independent of Inflammation of 



its Texture. By Dr. Robt. Tay- 
lor. - - 252 

61. Diphtheritic Conjunctivitis 
and the Application of Caustic 
in Acute Inflammation. By Dr. 

A. Von Graefe. - - - 253 

62. Trephining the Os Unguis for 
Fistula Lachrymalis. By M. 
Demarquay. - - - - 254 



Midwifery. 



63. Case of Presentation of the 
Bladder in Labour. By Alex. 
Harvey, M. D. - - - - 254 

64. Abnormal Quantity of Liquor 
Amnii. By Dr. James A. Sidey. 255 

65. Cases of Placenta Prsevia. By 
Mr. F. F. Giraud. - - - 256 

66. State of the Foetal Pulse as an 



Indication for Artificial Deli- 
very. By Prof. Simpson. - 257 

67. Epidemic Puerperal Fever 
which recently prevailed in the 
Dublin Lying-in Hospital. By 

Dr. McClintock. - - - 257 

68. Resorption of the Placenta. 

By Dr. Sabatier. - - - 264 



Medical Jurisprudence and Toxicology. 



). Prolonged Retention of Life 
by Infants who have not Breath- 
ed. 264 



70. Lead Poisoning ; the Artisans 
who are most Exposed to it. By 
Dr. Bierbaum. - - - - 266 



12 



CONTENTS. 



AMERICAN INTELLIGENCE. 
Original Communications. 



PAGE 

Haemoptysis successfully treated 
by the Horizontal Position and 
Cold to the Chest. By Wm. H. 
Byford, M. D. - - - - 267 

Hydrocele successfully treated. 
By Bedford Brown, M. D. - 268 

Emmenagogue Properties of Cha- 
momile Flowers. By H. T. 
Brown, M. D. - - - - 268 



Tapeworm Expelled by Infusion 
of Pumpkin Seeds. By D. Lea- 
sure, M.D. - - - - 269 

Rheumatism (Rheumatismus va- 
gus seu dolens) successfully 
treated with Atropa Belladonna. 
By B. Roemer, M. D. - - 269 



Domestic 

Extirpation of the Uterus. By Dr. 
G. Kimball. - - - - 270 

Gastrotomy successfully perform- 
ed for the removal of a Bar of 
Lead from the Stomach. By 
Dr. John Bell. - - - - 272 

Wound of the Stomach ; Recovery. 
By Dr. C. Happoldt. - - 273 

Luxation ofthe Head of the Radius 
backward, with Fracture of the 
Inner Condyle of the Humerus. 
By Dr. Thomas M. Markoe. - 274 

Treatment of Pneumonia. By Dr. 
John T. Metcalfe. - - - 276 



Summary. 

Operation under the Influence of 
Local Anassthesia, induced by 
Cold. By Dr. L. A. Dugas. - 279 

Case of Double Uterus ; both Im- 
pregnated. By Dr. J, T. Kan- 
non. 279 

Dislocation of both Thigh Bones, 
with Laceration of Ilio-sacral 
Ligaments, and Displacement of 
the Right Os Innominatum. By 
Jno. I. Hodgen, M. D. - - 280 

American Medical Association. - 281 



Ani. Journ.Ied. Sd.Vol IXXJ.S 



Plale 1. 




T. Sinclair's litk PtJ- 



BdRSTLERS CASE OF COMPLEX HEPATODYM MONSTER 



Am. Jmirn.led.Scl.Yol.m.N.S. 



Plate II. 





BdRSTLER'S CASE OF COMPLEX HEPATODYM MONSTER. 



THE 

AMERICAN JOURNAL 
OF THE MEDICAL SCIENCES 

FOR JULY 1 8 55. 



Art. I. — Case of a Monstrous Birth — described in a Letter from Dr. Gr. W. 
BcERSTLER, of Lancaster, Ohio, to Dr. Meigs, of Philadelphia — with re- 
marks on the Case. By C. D. Meigs, M. D., Professor of Midwifery, &c., 
in Jefferson Medical College. (With two lithograph illustrations from 
Daguerreotypes by Root.) 

Case — Dear Sir : In compliance with my promise, I now give you a his- 
tory of the highly interesting, and, as far as I have had the means of refer- 
ence, altogether unique monstrosity. 

On Tuesday evening, 16th January, I visited the wife of one of our most 
respectable citizens, who was in her ninth labour ; the uterine contractions 
being strong, and at fifteen minutes' intervals. At 7 o'clock I touched, and 
found the os high up the sacrum, and dilated to a dime's size. 7 J o'clock, 
touched again — os dilating rapidly^ 8 o'clock revealed it fully dilated, and 
the membranes slightly protruding. 

This examination gave the impression that a knee or elbow presented, and 
I at once placed the mother in the usual position for turning. I could not 
satisfy my mind as to the presenting part, and therefore ruptured the mem- 
branes, and then felt what I believed a groin, the hip resting in the left 
iliac region, the body oblique across the maternal pelvis. Into this supposed 
groin I hooked two fingers, and, with some little traction, brought the breech 
into the proper axis of the pelvis, congratulating myself on finding only an 
ordinary breech presentation, which would give me little trouble. 

Waiting to see whether the foetus would now advance, and finding this 
not so, after some very vigorous throes, I again introduced the left hand, 
for the purpose of bringing down the inferior extremities; and, feeling the 
supposed groin, I slipped up my hand to the knee, and in attempting to 
flex it I was foiled. Continuing the examination of this limb, I felt the 
spinal column along, and parallel to it. Reflection could bring to my mind 
no such presentation, and, partly withdrawing the hand to search for the 
No. LIX.— July 1855. 2 



14 



Meigs, Case of Ilepatodym, with Reraarhs. 



[July 



fetal pelvis, I found the two lower extremities flexed on its abdomen, both of 
which I brought down, unfortunately separating the left femur from its epi- 
physis. 

Having now three legs to deal with, the idea of twins was naturally fixed 
in my mind. The uterine contractions being vigorous, and the tractile force 
applied greater than in ordinary breech cases, I believed the leg of the other 
child to be the impeding obstacle, and at once introduced the hand to correct 
the entangled posture of the tivins ; carefully feeling this third leg, I found 
it firmly united to the body of tlie child whose two legs I had brought down, 
and arising from the dorsum of the ilium. A malformation was now evident; 
its character unknown. Hookin^; two fingers above the attachment of this 
back leg, and grasping the two other thighs with the right hand, I acted with 
considerable force on these two points, and found the pelvis and body of the 
child gradually advancing through the inferior strait, until it reached the 
junction of two bodies united by an intergrowth of the ensiform cartilages. 
At this point I met the greatest resistance during the labour. This being 
happily overcome, I found two bodies diverging from each other, which, how- 
ever, passed the strait without much trouble and, by passing the hand up, I 
felt two apparently well-formed heads, each as large as that of an ordinary 
child. To my mind it seemed impossible that those two heads could pass the 
strait at once, and I looked to the probable necessity of lessening one or both; 
but, to my great gratification, they passed without any extraordinary efforts 
being called for. This could nob have resulted, but for the good fortune of 
the head of the smaller child resting upon the neck and cheek, up to the ma- 
lar bone, of the larger. Thus was completed a delivery of a most extraordi- 
nary lusus naturae, to the well-being of the mother and children. The mother's 
recovery was rapid ; the children are living — one vigorous, the other feeble ; 
both take food, and urinate and defecate. There was one ordinary placenta, 
and one cord. 

Description of the children. — The heads, faces, arms and hands, and the 
chest down to the ensiform cartilages, are well developed and in proper pro- 
portions. From the junction downwards, one body, its anterior surface from 
side to side broader than in an ordinary child ; the abdominal muscles well 
developed ; the umbilicus in situ ; two spinal columns, perfect; the coccyx of 
each terminating on each side of the anus, and about half an inch from it ; 
two pelves united, the left one belonging to the larger child, encroaching upon 
and lessening that of the right side. The sex female; one vulva and one 
anus, the opening of the latter not larger than an ordinary rye straw — the 
two lower extremities are of proper size and proportions. Upon the back, 
and from the dorsum of the two ossa ilia arises a leg running up between the 
two spines and the two inner shoulders, and terminating in a right and left 
foot joined at the heel. This is, in truth, a double leg, enveloped in one 
common integument, having two femurs, two tibias, and two fibulas; the leg 
admits of partially moving it directly backwards to a distance of several 



1855.] 



Meigs^ Ca^e of Hepatodym, with Remarhs. 



15 



inches from the back of the child. I have no doubt that nature designed 
one of these legs for each child — for, when the right child is awake, it moves 
its lower extremity, as also the left foot of the double leg ; when asleep, the 
limb is quiet; and so with the other child. Tickling the sole of either foot, 
movem^t follows in the limb ; ^ but I have not perceived motion in the oppo- 
site leg to the one tickled. The two bodies have each its heart and lungs ; 
puerile respiration distinct; the action of each heart easily felt; though the first 
and second sounds cannot be distinguished, owing to the rapid systolic and 
diastolic movem.ents. So far as I have been able to detect, I believe the re- 
spiratory and cardiac action of both children to be synchronous, though the har- 
mony of the former is interrupted by the crying of either child. I have fre- 
quently observed that, when one of the children is nursing and the other 
crying, the latter falls asleep; so frequent is this occurrence, that I hold it 
to be the rule, and it shows the strong sympathetic relations between these 
tico distinct human heings joined in one. What the union of organs may be 
in the abdominal cavity we, of course, have no means of knowing ; all rea- 
soning thereon must be hypothetical. That the viscera are duplicated, we 
think probable. In the feeble child there existed the anomaly of the frsenum 
lingude arising from the dorsum of the tongue, about half an inch from the 
tip, and inserted into the palatine arch, of course rendering the tongue use- 
less in sucking. 

The following admeasurements were made, in the presence, and by the aid 
of Drs. Effinger, Davis, and Wagenhals. Owing to the want of calipers, the 
circumference was taken 

Occipito-frontal, 13 J inches in the larger, 12 J inches in the smaller; bi- 
parietal, 6 inches — 5 J inches. This is half the circumference, having mea- 
sured from one parietal protuberance to the opposite, across the vault. 
Mental, 4f inches— 3 1 inches; occip. bregmatic, 13 J inches — 13 J inches; 
shoulders, 10 inches — 9 inches; junction of bodies, 16 J inches; pelvic, 13 J; 
length from head to foot, 17^ inches — 17 inches; weight, 10 pounds. 

These are the facts in this, to me, exceedingly interesting case, and I very 
much regret the absence of men fully capable to examine it in all the lights 
which our science demands from its votaries. In the development of embryos 
in utero, certain starting points are always essential to the production of par- 
ticular organs or limbs ; this law is clearly manifested in the production of 
the double leg — for in the fusion of the two pelves, the acetabular portion is 
preserved, and hence the development of this extra limb. 

K letter from Prof. Meigs refers me to the great work of M. Serres, on 
Monstrosities; to it I have no access, but from the Professor's letter I learn 
that a specimen, approaching mine, was born in Sardinia a few years ago, and 
brought to Paris for public exhibition. The union in this case was in the two 
pelves, and called, by M. Serres, a hepatodi/m. In mine, the union is from 
the xiphoid cartilages down ; and, hence, I ask if it is not properly called an 
hepato-pelvidym ? 



16 



Meigs, Case of Hepatodym, with Remarks. 



[July 



Death of the children. — On Tuesday morning, 20tli February, the mother 
observed the larger twin gasp a few times, and at fifteen minutes before 6 
o'clock breathing ceased. At 8 J o'clock I saw it, and could not detect any re- 
spiratory act, nor pulsations of heart or arteries. Drs. Effinger and Wagenhals 
pointed out to me the apparent movements of the carotids. We, however, all 
became satisfied that these movements depended vpon the circulation of the 
smaller child. The asphyxiated condition continued for four and a half 
hours; no respiration ; nopidse; the capillaries of the sM^i filed with dark 
hlood, giving a purple hue to its entire body, and beautifully showing the de- 
marcation between the asphyxiated and living child. This line from the 
junction down, extended half an inch lo the right side of the umbilicus. A 
violent effort in coughing by the smaller child communicated a shock to the 
larger, convulsive movements of its limbs followed, and it uttered a few feeble 
cries, when it again relapsed into its condition of suspended animation, and so 
remained till 5 o'clock in the evening, when the smaller child died. One 
gasp in the larger, and in ten seconds it slept with its sister. Thus these 
children fortunately survived their unfortunate union only five weeks. 

Accompanying this history you will have daguerreotypes of the front, 
back, and side views. These pictures are fac similes of the original, and exe- 
cuted by my fellow-townsman, V. M. Griswold, in his usual style of accuracy 
and beautiful finish. 

You have seen the children, and I ask you to add to the above any re- 
marks and reflections you may think proper. 

Believe me to be truly your obliged friend, 

To Prof. C. D. Meigs. G. W. B(erstler, M. D. 

I cannot allow the present opportunity to pass without expressing my 
thanks to Dr. Boerstler for his liberal kindness in sending me this valuable 
specimen as an addition to my collection in the Museum of Jefierson College. 
I am indebted to his kindness also for the privilege of presenting the accom- 
panying lithographs, taken from crayon-size daguerreotypes by Mr. Root, an 
inspection of which may show the reader the external peculiarities of the 
specimen. It is with Dr. B.'s consent that I have caused them to be pre- 
served entire, instead of destroying them by a dissection, which appeared to 
me wholly unnecessary, since the children so closely resemble in every par- 
ticular those that were dissected by the late Mr. Serres, and delineated by 
him in the Atlas to his work entitled Anatomie Transcendente. 

The birth of so curious a specimen of humanity as that described above by 
Dr. Boerstler would hardly fail in any part of the world to excite feelings of 
astonishment among the people, because it would present an appearance of 
mystery not to be accounted for, except by persons duly instructed as to the 
causes of such strange combinations. No surprise, however, would be ex- 
perienced were it understood that the development of such a monster is due 
to the regular operation of natural laws, which, by a mere accident, have been 
diverted from a normal way of action. 



1855.] 



Meigs, Case of Hepatodi/mj with Remarks. 



17 



Most persons, unacquainted with the doctrines of embryology, would re- 
gard such a creature as a double child, and such an opinion would tend to 
increase the astonishment of the observer, since any excess in the produc- 
tion of parts or organs is known to be in absolute violation of the powerful 
and invariable law of species or specific forms. But there would be no sur- 
prise if it were everywhere understood that it is not a double child that has 
been thus unfortunately born, and that the specimen represents two distinct 
individuals, who have become more or less completely fused or welded together 
in the womb, each depriving its twin sister of certain parts of its organization. 

In regard to the specimen now under consideration, it requires only a 
casual glance to see that the child on the right has contributed one-half of the 
abdomen, and the left child the other half. The two livers have become com- 
pounded into one mass, constituting what Mr. Serres, in his anatomy of Ritta- 
Christina, denominates a complex hepatodym; a word derived from Jievar and 
didj/mus. 

These complex hepatodyms always result from a lateral union of twins in 
the womb, according to Mr. Serres, because in every instance of such lateral 
union the livers must become compounded together into one mass composed 
of those two individual organs. In case, however, the union of the twins 
should take place in front, that is, face to face, or nearly so, then the result is 
the production of an acomplex hepatodym, a case in which the livers remain 
separate. 

The complex hepatodym gives two heads, and, for the most part, two trunks 
with four arms; whereas the acomplex hepatodym gives one compound head, one 
thorax, two arms, four bellies, and four lower extremities. In either of these 
cases there must be combination or fusion of some portion of the bowels of 
the children, owing probably to changes or obstruction, at a very early stage, 
in the arrangement and distribution of the omphalo-mesenteric bloodvessels, 
and the excretory tubes of the two umbilical vesicles. 

•When the union takes place laterally, we therefore should find a pelvidym ; 
and when it takes place in front, we ought to have a cephalodym, because the 
complex hepatodym implies that the two pelves are compounded more or less 
completely, and the heads separate, while the acomplex hepatodym implies that 
the two pelves shall remain separate, but the thoraces and heads compounded 
together under one form. 

The lateral union is sometimes so complete as to present the appearance 
of a very perfect single child, having two well-formed heads growing from 
common and perfect shoulders. To show that this is the case sometimes, I 
annex a wood-cut taken from a life-size portrait by Mr. Jno. Neagle, an 
account of which I have already published in my work called Obstetrics, the 
Science and the Art, at p. 220. 

An inspection of the wood-cut shows that while there was a single pelvis, 
abdomen, and thorax, there were also two sets of cervical vertebrae, and pro- 
bably two sets of at least a large moiety of the dorsal range of vertebrae. It 



18 



MeigS; Case of Hepatodijm, vntli Remarhs. 



[July 



is not known how far downwards in the ranges the duality of the rachis pro- 
ceeds before it acquires its condition of unity. It is at least evident that the 




duality IS lost m unity m the lumbar series, 
and that only a single sacrum could exist in 
the specimen. Indeed, I have sometimes 
thought that it might have been possible, in 
this very case, that the union should have 
gone even further, so as, in fact, to have con- 
founded the two heads into one, leaving the 
spectator in doubt and uncertainty as to 
whether he had before him one child, or two 
half children united into one. It is, how- 
ever, to be believed that Mr. Serres's law as 
to the complex and the acomplex hepatodym 
is invariable, and that in every instance we 
can have ojily a pelvidym on the one hand or 
a cephalodym on the other. 

To look at my wood cut, or to examine the 
lithograph, it becomes clear that the left child 
is an absolute identity, while the right one 
equally retains its unity or individuality. The 



left child, which has its head and left arm en- 
tire and perfect (vide wood-cut), has also preserved half of its thorax, abdomen, 
and pelvis ; i. e., it has the left half of its sacrum and the whole of its left os 
-innominatum. The conservation of its left os innominatum implies also the 
conservation of its left acetabulum, which may be fancifully compared to a 
bud from which to develop its left leg and foot, which are accordingly seen to 
be in all respects complete. This left child lost its right os innominatum, 
and, having no right acetabulum, could by no means develop a right leg, 
which is a dependency of that acetabulum. The same observations apply to 
the child on the right, mutatis mutandis. 

When the embryos came together in mutual contact they became fused or 
welded by a process not dissimilar, I suppose, from that called by gardeners 
enarcliing, or budding, or grafting. The dermal surfaces are not formed at a 
very embryonal age, and contact leads to fusion or blending as certainly as 
contact of freshly incised surfaces leads to surgical union by the first intention. 
And this is what has happened in Dr. Boerstler's specimen, in the case repre- 
sented by the wood-cut, in Ritta- Christina, and probably in all the cephalo- 
dyms and pelvidyms that have appeared to astonish the world. Individuality 
or personal identity is not lost in such cases, for the specific or generic law 
operates invariably ) and, though each of the children has lost somethiDg, it is 
a loss by default only, and is never a case of excess. 

In Dr. Pfeifi^'er's case {vide wood-cut) there were, doubtless, two independent 
stomachs. The duodenum of each child was separate, as well as the jejunum 



a855.] 



Meigs, Case of Heipatodym^ with Remarks. 



19 



and part of the ilium, but one-half of the lower part of the ilium, the caecum, 
colon, and rectum was lost by each embryo respectively, each of which con- 
tributes its half of the cgecum, colon, and rectum, one ovary, half the bladder 
of urine, half a clitoris, nympha, vagina, and womb, the remainder being mu- 
tually lost by default. As there is only one navel and umbilical cord, it is 
true to say that each child owns one-half, as well as half of the allantois, one 
umbilical artery, and probably one-half of the umbilical vein. The con- 
founding together of some part of the small intestines, which must lose their 
duality, is an unavoidable result of the early confusion of the omphalo- 
mesenteric system, and the tubes of the vesicles or vitellary sacs. 

To touch and tickle the left foot, while the child was sleeping, would be to 
waken it and cause it to smile, without exciting any reflex or other sensibility 
in its twin brother. 

When Ritta's foot was tickled, it did not wake the sleeping twin Christina, 
and vice versa. Dr. Boerstler observed the same phenomenon in his cases. 

There appears to me, upon the whole, to be less matter for surprise at wit- 
nessing the birth of such twins than there is in the reflection, how rare are 
the eases. Thus, Madame Lachapelle, who had the superintendence of more 
than thirty-seven thousand births while she was at the head of the Maternite 
at Paris, found only 444 cases of twins in that great number, which affords 
about one twin case to every one hundred births. I have no means of know- 
ing how many cases of monstrous births like that under consideration may 
occur in the course of a year : I should suppose, however, that three or four 
such instances would hardly be met with, in every year, in the whole globe; 
though it is computed that 24,000,000 of children are born annually. And 
this leads to the inquiry. What is the cause of such abnormities, or what is the 
reason why they do not oftener occur ? 

If a gardener, in performing the act of enarching, or budding, or grafting, 
should place a bit of membrane betwixt the surfaces to be united, he would 
wholly fail of success. In like manner, if two or more children should be 
carried in the same womb, there would be interposed betwixt their growing 
surfaces a membrane produced by each embryon, the amnios; the interposition 
of which would effectually debar the possibility of such unfortunate conjunction 
of the fruit of the womb. It may, therefore, be safely assumed that, wherever 
the amniotic sac is in a normal state, such unhappy duplicity as in the case be- 
fore us is rendered impossible ; and, consequently, that all such instances of 
conjunction are events that depend upon rupture or incomplete development 
of the amnion. I have purposely left out of question the state of the chorion, 
because I do well know that, although in twin pregnancies there are sometimes 
found two absolutely distinct chorions and placentas, there are very numerous 
instances in which both of the children, and sometimes three, are contained 
within a single chorion, on the outer surface of which is developed a single 
placenta. This observation I have made so carefully, and so many different 
times, that I rest assured of the correctness of the opinion. But in all these 



20 



Meigs, Case of He^atodym^ with Remarks. 



[July 



examples of a single chorion covering twins or triplets, I have invariably 
found a distinct amniotic sac enveloping each child. Indeed, I cannot well 
conceive of an embryo in the womb as existing without its amnion, save in 
the cases where it is absent by default of arrest of development, or by acci- 
dental rupture. 

I fully conclude, therefore, that the cause giving rise to the hepatodym-mon- 
ster, whether it be complex or acomplex, and no matter how or where the 
union is effected, is a dependency on the accidental imperfection of the 
amniotic sacs of the twins ) and that it is necessary that both of the amnions 
should fail, since the existence of a single one must prove an effectual bar 
against the union of the embryons. 

It is well known that in the complex hepatodym or pelvidym, although 
there is never more than one navel and cord, there may or may not be de- 
veloped, in addition to two perfect lower extremities, other mdimental limbs, 
more or less complete — a case that is strictly dependent upon the amount of 
injury done to or of interference with the development of the acetabulum. 

Dr. Boerstler describes the singular leg that is seen in my lithograph lying 
upon the back of the conjoined twins. This member is inclosed in a common 
tegument, and rises up along the posterior surface of the hepatodym, and loses 
its apparent, but unreal unity, only at the tarsus, where the two imperfect 
organs acquire a visible duality. To show that they belong each to a distinct 
individual. Dr. Boerstler made the experiment of tickling the foot, which the 
reader has noticed in the doctor's interesting letter. To examine the speci- 
men, or even to scan these lithographs, one may readily solve the problem as 
to the apparent unity of these two hind legs, as I may call them. In Ritta- 
CJiristina,2Li[id in Dr. Pfeiffer's case (^vide wood-cut), the fusion of the pelves 
in their lateral union was so complete as to make it impossible to produce 
more than two legs. (See M. Serres, Plate XL of the skeleton of Ritta- Chris- 
tina.') That gentlemen gives us, in Plate XX., the skeletons of united twins, 
having a perfect right and left leg to each, an abortive left leg for the right 
child, and only a rudimental right femur for the left child. 

Let the reader look again at my lithograph to see that, in the lateral or pel- 
vidym union of these two children, there was a tendency of the embryons to 
approach each other face to face, and that the contact took place in such a 
way as to cause fusion and partial arrest of development of the horizontal or 
body-portions of the left and right pubes. Now, as the pubis contributes one- 
fifth of the acetabulum, and the ischium and ilium each two-fifths, it has hap- 
pened that the pubal fifths of the two acetabula were arrested and lost, and that 
the ischial and iliac two-fifths of each party being left unruined, there sprung 
from them the curious back leg which thus lost, apparently, its duality, which 
has been unavoidably inclosed within a common integument, and was com- 
pelled to take its place upwards along the dorsal region. 

If the turn on their axes had been a backward instead of a forward turn, it 
is probable that this compound and imperfect leg would have been developed 
in a direction upwards, and in front of the common abdomen. 



1855.] '^di'mmoudi. Medical TopograpTiy of Fort Reading y Cal. 21 



In regard to the obstetric peculiarities of such caseS; it may not be inap- 
posite for me to remark that Dr. Bcerstler ought to be esteemed fortunate in 
having so rare a case as this to offer itself in a pelvic presentation. It is, 
probably, to that circumstance that he owes the opportunity he enjoyed of 
seeing the twins survive their birth so long. 

If they had offered to him a cephalic presentation, it is scarcely to be be- 
lieved he could have extricated them alive. The wood-cut, so often referred 
to, may be examined with a view to discover what must be the effect of a 
head-presentation in such a case. 

If we suppose the left head to present at the superior strait, and to be 
driven out in front of the genital fissure, we cannot conceive of the right one 
as immediately following it. On the contrary, the right one must remain 
above the brim, and the left one in front of the pubis; the two heads being 
separated by the symphysis pubis. They may be likened to two sleeve but- 
tons, each buttoned in a wristband. The inner or upper head cannot escape, 
because the left shoulder occupies the opening, for the escape of the left head 
has converted the vertex case into one of what is called shoulder-presentation. 
It is impossible to perform the operation for turning here, because that opera- 
tion consists in carrying the presenting part up towards the fundus, and bring- 
ing another part, as the feet or breech, to present. Clearly, the now presenting 
part, which is a left-shoulder, cannot be carried up towards the fundus, for it 
is chained to the strait by the head already born, which firmly holds the 
shoulder to its presentation. 

Pfeiffer's case was of this kind, and the children could not possibly be born 
save by the act of what is technically denominated evolution of the foetus, 
usually spoken of as spontaneous evolution in shoulder-presentations. 

I shall not presume here to explain what is meant by spontaneous evolution 
of the foetus, for it is to be supposed that every reader of this journal is per- 
fectly acquainted with a subject so trite. It is highly proper for me, how- 
ever, to say that, in the obstetric operation, the attending practitioner may 
always, however embarrassing the case, confide in his ability to deliver the 
woman, provided he will first reflect upon the mechanism of these spontaneous 
evolution cases ; and, if compelled to do so, resort to a compulsory process of 
evolution, in which he shall cause the foetus to undergo the same changes as 
those that take place in unassisted deliveries of shoulder-presentations. 



Art. II. — A Sketch of the Medical Topography of Fort Reading j California. 
By J. F. Hammond, M. D., Assistant Surgeon U. S. Army. (Communi- 
cated by Thos. Lawson, M. D., Surgeon General U. S. A.) 

As it is the impression in this department generally that this post will be 
broken up next spring, I take advantage of a quiet time to write you a hasty 
sketch of its medical topography. 



22 Hammond^ Medical Topography of Fort Reading, Col. [July 

The meteorological tables, and the others relating to the sick, are condensed 
from the retained copies of the Meteorological Register and the Register 
and Quarterly Reports of the Sick and Wounded in the Post Hospital ; for 
which observations up to the first of December last, credit is due to the 
medical officers who preceded me here. 

This military post was established in May, 1852, and was named Fort 
Reading, after an old settler from one of the Eastern States, who still lives 
in the neighbourhood. 

It is in latitude 40° 28' 22" N. ; longitude 122° T W. from Greenwich. 
In altitude about 800 feet above the level of the Sea. The country around 
is, in a general view, an irregular prairie, bounded on the east by a range of 
mountains — Lassen's Mountains — running north and south, sixty miles distant, 
and one-fourth of the way to the range of the Sierra Nevada ; on the west by the 
Coast Range, twenty-five miles distant ; on the north by Shasta Butte, ninety 
miles distant, which appears to spread out east and west, and connect with 
Lassen's and the Coast Range ; and on the south it is continuous with a plain 
that follows the course of the Sacramento River. The average height of 
these mountains is five or six thousand feet above the sea. The highest point 
of Lassen's Range — Lassen's Butte — which is nearly due east from the fort, 
must be near 10,000 feet above the sea. Snow is seen on it at all seasons. 
Shasta Butte, which is immediately under the 122d parallel, is, according to 
the most reliable map of Northern California, 1G,600 feet above the sea. It 
is covered perpetually with snow for some distance below its summit. Three- 
fourths of the horizon is, in winter, bounded by a line of snow. 

This large basin is the northern part of the valley of the Sacramento 
River. Its inclination is to the south. It is furrowed everywhere by ravines 
and valleys, in which, from October to May, are flowing mountain torrents. 
The last vary in size from the smallest to a quarter of a mile broad, and have 
an average depth of many feet. The remainder of the year the ravines con- 
tain strings of pools of stagnant water, alternating with sandy or rocky beds, 
exposed to the rays of the sun. The prairie is studded here and there with 
moU of white oak ; and white oak, the nut pine, and willows, with long grass 
and dense undergrowth, skirt the water-courses. Elsewhere the country is bare 
of everything that would intercept the winds. The population, which is com- 
posed of emigrants and a few small bands of roving Indians, is, except in the 
mines, very sparse. The cultivation of the soil is of such little extent that 
it cannot efi"ect in any degree its healthfulness. 

The post is a mile east of the Sacramento River, in the valley of a moun- 
tain stream called Cow Creek. It is on the brink of the bank, twenty feet 
high, which limits the bed of the creek on its western side, in a fine grove of 
large white oaks entirely free from undergrowth. The quarters for the officers 
and men are of adobes, one story high, of ample dimensions, well ventilated 
except beneath the floors, which are of planks laid directly on the ground ; 
they are well lighted, and the distances between the buildings spacious, so as 



1855.] 'E-diXYimoTi^, Medical Topography of Fort Readwg, Cal. 23 

to allow free access and circulation of fresli air. The whole is thoroughly 
policed. The creek^ generally confined between its banks, sometimes over- 
flows just above the fort, and forms a stream fifteen yards or more in width, 
that runs between the buildings occupied as quarters, and leaves a damp and 
fetid bed. It was found necessary to build a permanent bridge over the bed of 
this cut olf, for such an emergency. During the winter and spring the creek 
has, for a mile or two above its mouth, an average depth of fifteen feet, and forty 
yards breadth. Its bed, however, will average one hundred yards wide. Just 
now the stream is, at the fort, 350 yards wide. In the summer and fall, the 
average depth is not more than four feet, its breadth is contracted two-thirds, 
and much of its bed, which consists of boulders, gravel and sand, or argillo- 
arenaceous layers containing a large amount of fragments and particles of 
pumice and vegetable remains, is exposed to the sun. When the stream is 
swollen by the rains, it has a yellowish-gray turbidness ; but the deposit is 
slight, from the short duration of the floods and its rapid current ; as it sub- 
sides, it has the opalescent hue of streams of limestone water ; and when at 
its summer height it is limpid, and delicious to drink. Its course is S. S. W. 
It runs a little nearest the eastern border of its valley, and empties into the 
Sacramento River, a mile below the fort. 

The valley of the creek is a mile wide. Its bottom is a plain of argillaceous 
soil mixed with gravel and vegetable remains from grasses and weeds. It 
produces a very full crop of grasses and weeds, and great variety of flowers. 
Is is exceedingly retentive of moisture, and is, during the rainy season, so 
boggy that it is dangerous for cattle to get off the roads. The subsoil is a 
light yellow sand, more or less compact. The valley has the appearance of a 
valley from disruption, and presents, on both sides, abrupt escarpments fifty 
feet high. The continuity of the latter is much interrupted by ravines formed 
by the rains, and the angles have been rounded, and the subsoil concealed by 
various meteorological causes. From the tops of the escarpments on both 
sides of the valley, extend plains to the foot of other precipices, or are inter- 
rupted by ravines and valleys. The surface of these plains are red clay mixed 
with gravel and the remains of crops of grass, and they are covered with 
rolled flints. In some places, over an extensive tract, they are formed into 
numerous depressions, which contain puddles or ponds of water during the 
rainy season. For some time after that season, even a man cannot walk on 
them .without miring. In summer they are dry and somewhat spongy, and 
water is found a short distance beneath the surface. The substrata are clay 
mixed with rolled flints, gravel, yellow sand, all of various degrees of com- 
pacture, but friable, extending to an indefinite depth. Cryptogamic plants 
are observed during most of the year. After a rain many mushrooms spring 
up ; mould fixes on the ground in numerous places, and seizes upon all fresh 
deposits of animal or vegetable matter. 

The following meteorological tables are from observations taken at this 
post, from June, 1852, to January, 1855, inclusive — a period of thirty-two 



24 Hammond, Medical Topography of Fort Reading, Cat. [July 

months. The thermometer, which is detached, is perfectly protected from 
reflection. 

The first is the mean temperature monthly : — 



The Monthly Mean of Four Observations per Day of the Temperature. 



Month. 
- 


Thermometer detached. 


Month. 


1 

Thermometer detached. | 
-i 


1852. 




,. ... 
1853. 




June 


78.80° 


November . . 


63.12° 


July . . . 


80.37 


December . . 


46.20 


August . . 
September 


78.75 






72.33 


1854. 




October . . 


59.76 


January . . 


49.00 


November . . 


51.77 


February . . 


47.26 


December . . 


43.42 


March. . . . 
April . . . 


53.14 
60.11 


1853. 




May . . . 


67.40 


January . . 


48.03 


June . . . 


72.11 


February . . 


49.37 


July . . . 


83.74 


March . . . 


52.34 


August . . . 


79.62 


April . . . 


58.77 


September 


72.67 


May . . . 


70.96 


October . . 


61.90 


June . . . 


78.50 


November 


53.60 


July . . . 


83.75 


December . . 


44.14 


August . . 


78.76 






September 


70.69 


1855. 




October . . 


65.06 


January . . 


44.20 



The next is the monthly mean of all the observations taken daily at sun- 
rise and 3 P. M.; and the mean monthly range of the thermometer. 



Mean Maximura and Minimum Temperature, and Mean Range of the Ther- 
mometer, Monthly. 



Month. 


Min. 


Max. 


Range. 


Month. 


Min. 


Max. 


Eange. 


1852. 








1853. 








June . . . 


62.26° 


96.26° 


34.00° 


November 


46.50° 


61.73 


15.23° 


July . . . 


62.35 


97.16 


34.81 


December 


39.41 


54.90 


15.50 


August . . 


62.25 


95.70 


33.45 










September . 


55.53 


90.73 


35.20 


1854. 








October . . 


45.80 


75.00 


29.20 


January . . 


34.38 


48.41 


14.03 


November 


45.86 


59.76 


13.90 


February . . 


41.46 


55.03 


13.57 


December 


40.19 


47.93 


7.54 


March . . 


45.02 


61.17 


16.15 










April . . . 


51.22 


69.17 


15.96 


1853. 








May . .. . 


65.32 


77.45 


18.13 


January . . 


42.06 


57.35 


15.29 


June . 


60.08 


83.08 


23.00 


February . . 


39.89 


60.35 


20.46 


July . . . 


69.28 


99.21 


29.93 


March . . . 


42.64 


63.93 


21.29 


August 


64.05 


95.01 


30.96 


April . . . 


49.20 


69.00 


19.80 


September . 


56.19 


87.26 


31.07 


May . . . 


55.64 


76.45 


20.81 


October . . 


54.06 


70.16 


16.10 


June . . . 


64,06 


93.20 


29.14 


November 


42.21 


68.11 


25.90 


July . . . 


67.48 


101.54 


34.06 


December 


34.15 


59.17 


25.02 


August . . 


62.51 


94.83 


32.32 










September 


56.73 


85.63 


28.90 


1855. 








October . . 


50.48 


81.22 


30.74 


January . . 


37.24 


55.18 


17.94 



1855.] TLdimmondi, Medical Topograjpliy of Fort Reading J CaL 25 

The next is the maximum and minimum temperature observed at any time 
during the month. 



The Hiyhest and Lowest Temperature at any time During the Month. 



Month. 


Min. 


Max. 


Month. 


Min. 


Max. 








loOo. 






June 


c -I o 


lUo 


November . 


O OO 


T !^ 


July . . . 


53 


106 


December . 


28 


66 


August . . . 


OD 


lUl 








September 




1 AO 


loOi. 






October 




oO 


January . . 


1 


/ i 


JsoYember , 


31 


87 


February . . 


32 


66 


December . 




/ 


JMarcli ... 


OO 


( 








April . . . 


40 


84 


1853. 






May .... 


44 


91 


January 


29 


72 


June . . . 


54 


96 


February . 


30 


68 


July ... . 


61 


110 


March . . . 


32 


84 


August . . . 


55 


108 


April . . . 


39 


83 


September . . 


63 


99 


May . . . 


46 


92 


October . . 


46 


98 


June 


51 


105 


November . . 


37 


84 


July .... 


56 


109 


December . . 


21 


71 


August . . , 


55 


104 








September . . 


51 


96 


1855. 






October . . 


40 


95 


January . . 


32 


72 



The next is the greatest range of the thermometer in any one day, and the 
least range in any one day of each month. 

The Greatest and Least Daily Range of the Thermometer^ Monthly. 



Month. 


Max. range. 


Min. range. 


Month. 


Max. range. 


3Iin. range. 


1852. 






1853. 






June 


47° 


21° 


November . . 


40° 


1° 


July .... 


43 


17 


December . . 


24 


1 


August . . . 


42 


11 








September . . 


53 


15 


1854. 






October . . 


44 


9 


January . . 


31 


1 


November . . 


37 





February . . 


25 


1 


December . . 


19 





March . . . 


30 


5 








April . . . 


33 


8 


1853. 






May .... 


25 


4 


January . . 


37 


1 


June . . . 


32 


8 


February . . 


33 


6 


July .... 


43 


17 


March . . . 


42 


2 


August . 


41 


14 


April , . . 


36 


1 


September . . 


36 


20 


May .... 


35 


1 


October . . 


43 


g 


June . . . 


39 


3 


November . . 


33 


14 


July. . . .. 


43 


27 


December . . 


33 


3 


August . . . 


43 


13 








September . . 


41 


14 


1855. 






October . . 


40 


11 


January . . 


38 


33 



26 'Rsimmondij Medical Topography of Fort Beading, Cal. [July 

The next is tlie temperature of the warmest and of the coldest of the 
thirty-two months. 



The Temperature of the Warmest Month and of the Coldest Month. 



1853. 


THERMOMETER. 


1854. 


THEKMO.METER. 


i 

July. Sunrise. 


9 A. M. 


3 P. M. 


9 P. M. 


Daily mean. 


Jan. 


Sunrise. 9 A. M. 


■i P. M. 9 P. M. 


CS-ii V TTi ftp 71 


1 


70° 


86° 


100° 


82° 


84.50° 


1 


41° 


48° 


60° 


40 


47.25 


2 


69 


90 


103 


83 


86.25 


9 


40 


43 


52 


40 


43.75 


3 


70 


89 


104 


89 


88. 


3 


31 


40 


52 


40 


40.75 


4 


71 


89 


99 


87 


86.50 


4 


31 


36 


50 


45 


40.50 


5 


60 


90 


103 


86 


84.75 


5 


33 


36 


41 


35 


36.25 


6 


75 


93 


103 


85 


89. 


6 


32 


40 


51 


33 


38. 


7 


70 


85 


101 


82 


84.50 


7 


32 


33 


48 


30 


35.75 


8 


68 


82 


98 


84 


83. 


8 


26 


31 


51 


43 


37.75 


9 


65 


84 


99 


82 


82.50 


9 


39 


49 


47 


36 


38.25 


10 


61 


81 


97 


83 


80.50 


10 


31 


35 


54 


48 


42. 


11 


69 


80 


89 


74 


78. 


11 


42 


46 


55 


47 


47.50 


12 


65 


78 


95 


72 


77.50 


12 


47 


48 


53 


51 


46.75 


13 


56 


81 


98 


77 


78. 


13 


54 


57 


62 


51 


56. 


14 


58 


85 


101 


79 


80.75 


14 


41 


42 


47 


■ 06 


41.50 


15 


63 


84 


101 


82 


82.50 


15 


31 


32 


36 


31 


32.50 


16 


63 


50 


1 no 




O^. / 


16 


o / 


37 

O 1 


38 


00 




17 


66 


84 


100 


85 


83.75 


17 


36 


36 


37 


35 


36. 


18 


68 


86 


96 


84 


83.50 


18 


33 


37 


40 


33 


35.75 


19 


68 


81 


102 


83 


83. 


19 


22 


25 


27 


20 


23^50 


20 


02 


91 


106 


82 


85.25 


20 


16 


21 




23 


og 


21 


65 


84 


105 


87 


85.25 


21 


15 


21 


34 


25 


53:75 


22 


69 


80 


96 


82 


81.75 


22 


24 


26 


41 


35 


31.50 


23 


68 


86 


102 


82 


84.50 


23 


35 


38 


41 


38 


38. 


24 


66 


90 


107 


84 


86.75 


24 


37 


38 


43 


40 


39.50 


25 


66 


89 


109 


88 


88. 


25 


39 


41 


54 


40 


43.50 


26 


69 


90 


105 


89 


88. 


26 


32 


39 


55 


38 


41. 


27 


75 


89 


105 


86 


88.75 


27 


35 


36 


60 


43 


41. 


28 


73 


90 


107 


90 


90. 


28 


40 


44 


57 


40 


45.25 


29 


74 


91 


105 


89 


89.75 


29 


40 


46 


71 


50 


51.75 


30 


73 


92 


107 


88 


87.50 


30 


36 


45 


66 


49 


49. 


31 


72 


92 


105 


85 


86. 


31 


38 


49 


66 


52 


51.25 


Mean 


64.03 


86.38 


101.87 


83.64 


84.51 


Mean 


34.29 


38.29 


48.74 


38.80 


39.51 



The mean temperature for the two months is, for July, 83.75°; for Janu- 
ary, 40°. 



1855.] TL^immoTi^, Med kdl Topograjpliy of Fort Reading J Col . 27 

The next is the hourly observations by the thermometer for twenty-four 
successive hours at the solstices and equinoxes. 



Hourly Ohservations of the Thermometer for Twenty-four successive Hours, at 
the Solstices and Equinoxes. 



























o . 

^ IM 

C CO 








C CO 




r-T 






T 


^ 




ffl r-l 


= i£ 




§1 


St !— 1 







H ^ 










a 






a: 










fi 


fi A AT 




390 


43° 


76° 


55° 


34° 


42° 


64° 


59° 


£3° 1 




49 


39 


46 


79 


59 


34 


46 


72 


63 


33 


I 


51 


40 


53 


81 


66 


34 


52 


74 


79 


35 


9 


60 


40 


61 


85 


74 


36 


56 




74 


36 


10 


66 


43 


67 


87 


81 


42 


61 


73 


79 


41 


11 


75 


43 


70 


91 


86 


46 


65 


74 


79 


53 


12 


81 


45 


73 


93 


90 


49 


68 


74 


84 


65 


1 P. M. 


83 


46 


76 


96 


92 


52 


70 


74 


86 


68 


2 


84 


46 




98 


94 


53 


70 


74 


87 


71 


3 


85 


45 


77 


97 


94 


54 


71 


75 


86 


71 


4 


83 


45 


76 


96 


93 


52 


70 


77 


86 


71 


5 


80 


44 


75 


95 


91 


51 


68 


78 


85 


68 


R 
U 


/ D 






QQ 
vo 


00 


4o 




77 


00 
b- 


bo 


7 


70 


44 


62 


90 


80 


45 


60 


74 


80 


59 


. 8 


65 


38 


59 


85 


75 


44 


58 


71 


76 


55 


! 9 


64 


38 


56 


81 


73 


44 


55 


67 


72 


53 


iio 

ill 


63 
61 


40 
88 


54 
53 


80 


66 


44 


53 
51 


60 
64 


67 


52 


i? 


63 


43 


61 


48 


!l2 


65 


39 


51 


76 


62 


42 


50 


60 


61 


48 


! 1 A. M. 


65 


38 


51 


75 


60 


40 


49 


59 


60 


46 


' 2 


65 


38 


49 


75 


58 


36 


48 


56 


58 


44 


1 ^ 


63 


37 


48 


75 


57 


35 


46 


56 


58 


44 


I 4 


59 


37 


47 


75 


55 


34 


46 


54 


55 


43 


' 5 


58 


36 


47 


75 


54 


34 


45 


53 


55 


43 


6 


56 


36 


47 


75 


54 


33 


45 


56 


53 


42 


1 Mean. 


66 


40.64 


59.44 


84.52 


77.20 


42.36 


52.36 


67.80 


71.04 


50.60 



28 Hammond, Medical TojpograpTiy of Fort Reading^ Col. [July 

The next is the monthly mean clearness of the sky. The figure indicat- 
ing no clear sky, and 10 an entire absence of clouds and haze; the numerals 
between those figures signify the degrees of cloudiness. 



The Monthly Mean Clearness of the Shy. 



Month. 


JlGan clcariiGss. 


Month. 




1852. 




1853. 




June 


8.50 


November .... 


3.50 


July 


8.75 


December .... 


2. 


August .... 


8.75 






September . . . 


8.50 


1854. 




October .... 


7.50 


January .... 


1.50 


November .... 


4.50 


February .... 


4.25 


December .... 


3. 


March 

April 


5. 

1.25 


1853. 




May 


6.50 


January .... 


5.25 


June 


6.50 


February .... 


6.25 


July 


8.75 


March 


5.75 


August .... 
September . . . 


8. 


April 


5.75 


8.75 


May 


5.75 


October .... 


4.75 


June 


8.25 


November .... 


6.50 


July 


9. 


December .... 


4.25 


August .... 


8.25 






September . . . 


7.50 


1855. 




October . . . 


7. 


January .... 


4.50 



The next indicates the points from which the wind is most prevalent dur- 
ing each month. It blows from every direction. There is very little strong 
wind at any season. 



The Prevailing Winds. 



Month. 


Month. 




1852. 




1853. 




June 


N. W., N., N. E. 


November 


E., N. E., N., S. W. 


July . . 


N. N. W., W., S. W. 


December 


E., N. E., N. 


August 


N.N.E.,E.,S.E.,S.,S.W. 






September 


N. N. W., N. N. E. 


1854. 




October 


E. N. E., N. E., N. 


January . 


N. W., N. N. W. 


November 


s., s. w. 


February . 


E., S. E., N. E., N. W. 


December 


s., s. s. w. 


March . . 
April . . 


N. W., S., S. W. 

N.,N. W.,&.S.W.,S.S.E. 


1853. 




May . . 


N. E., N., N. W. 


January . 


E.,N.E.,N.N.W.,S.S.W. 


June . . 


N. N. W., S. S. W., S. 


February . 


N., N. W., 

N. W., N. E., E. S. E. 


July . . 


N., N. W., S. S. W. 


March . . 


August 


S. S. W., N. N. W. 


April . . 


N. N. W., S. W., S. E. 


September 


N. N. E., S. E., S., S. W. 


May . . 


S. E., S., S. W. 


October 


W, S. W., N. W., N. E. 


June 


N., N. N. W. 


November 


N. W., N. E. 


July . . 


N. E., N. W., S. W. 


December 


N. W. 


August 


N., N. E., S. E., S. W. 






September 


W., S., E., N. E. 
E., N. E., N., N. W. 


1855. 




October . 


January . 


N. E., N. W. 



1855.] Hammond, Medical Topogrophy of Fort Reading, Cal. 29 

The next shows the quantity of water in the form of rain or snow that has 
fallen monthly. 



The Quantity of Rain. 



Month. 


Inches. 


Month. 


Inches. 


vouJL. 




lOOo. 




June 


l.Uo 


November 


O FiO 
L.uZ 


July 




December .... 


O 1 Q 


August .... 








September 




lOO'i. 




October .... 


Ao 


J anuary .... 


9 on 


November . . . 


8.48 


February .... 


.21 


December .... 


11.18 


March 








April 


3.07 


1853. 




May 


2.40 


January .... 


4.66 


June 




February .... 


3.18 


July 




March 


7.11 


August .... 




April 


4.57 


September . . . 




May 


.70 


October .... 


2.26 


June 




November . . . 


.87 


July 




December . . . 


1.45 


August .... 


.24 






September . . . 


.02 


1855. 




October .... 


.02 


January .... 


3.69 


Total, 63.31 



Of the sources to which have been referred the causes of intermittent 
fever, several are well marked here. For example : an argillaceous soil con- 
verted into a swamp during one-half the year, and presenting during the other 
half a dry, spongy surface, with water at a little depth beneath it; a pro- 
longed rainy season, followed by one of dryness and intense solar heat; nu- 
merous beds of streams exposing dry surface or pools of stagnant water to 
the sun, especially one immediately beside us ; the free passage of the winds 
in various directions ; the great diurnal range of the temperature ; the general 
growth of cryptogamic plants ; aud the grove immediately around us, the ex- 
halations from which may chill the atmosphere at night, or shed down poison- 
ous emanations intercepted by the leaves. 

The intermittent fever occurs here at all seasons. A violent attack of ter- 
tian intermittent occurred in an ofi&cer late in December last, just after fifteen 
successive mornings of white frost. A light shower followed the last frost, 
which was in turn followed by four frosty mornings, and on the second day of 
the last he was attacked. He arrived here for the first time seventeen days 
before his illness, and there is no reason to believe that he had contracted the 
disease elsewhere. The disease is perfectly controllable by the sulphate of 
quinia. 

The following table is from the Reports of the Sick and Wounded at this 
post, made to the Surgeon Greneral : — 
No. LIX.— July 1855. 3 



30 Hammond, Medical Topoyroj)hy of Fort Reading, Cat. [July 



Report of the Sich and Wounded at Fort Reading, California, for 



MONTH. 


FETEES. 


DISEASES OF THE 
ORGANS CONNECTED 
■NTITH THE DIGESTIVE 
SYSTEM. 


THE RESPI- 
RATORY 
SYSTEM. 


THE BRAIN 

AND 
NERVOUS 
SYSTEM. 


THE URIN- 
ARY AND 
GENITAL 
ORGANS. 


THE SE- 
ROUS EX- 

HALANT 
VESSELS. 


THE FIBROUS 
AND 
MUSCULAR 
STRUCTURES. 


Feb. cont. comm. 


Feb. int. quotid. 


1 Feb. int. tertian. 


1 Feb. int. quart. 1 


1 Febris remittens. | 


ci 

'o 
O 


"o 


P 


eS 

D 

o 
ei 

.2 

a; 

S 

i? 


.2 

a 

a 


Obsti patio. 


oi 

S 


a 

o 


a 

< 


c 

c 

03 

.ti 

c 

p 


c: 


■i 

5 


1. 

d 


Delirium tremens. 


1 
cS 




: : : : Gonorrhoea. 


■i 

O 



o 

1 
< 




a: 
■3 

-< 




: : : j Periostitis tibialis. | 


r! 




i 

3 

Si 

1 
1 

2 
3 

4 
4 
1 
1 


1852. 
June . . . 
July .... 
August . . . 
September 
October . . 
November . . 
December . . 

1853. 
January . . 
February . . 
March . . . 
April . . . 
May .... 
June . . , 
July .... 
August . . , 
September 
October . . , 
November . , 
December . . 

1854. 
January . . 
February . . 
March . . . 
April . , . 
May .... 
June . . . 
July .... 
August . . . 
September 
October . . . 
November . . 
December . . 

1855. 
January . . 




7 
33 
46 
44 
33 
20 
16 

14 

23 
26 
29 
23 
18 
29 
66 
42 
63 
43 
22 

23 
16 
23 
21 
24 
24 
36 
40 
30 
36 
14 
7 

6 


3 
2 
1 
2 
2 
1 


1 


2 
2 


1 


1 

3 
5 
1 

1 
1 

1 


7 
5 
1 

9 
5 
1 

3 
2 
2 
1 


2 
1 
3 
6 
1 


1 


1 




2 




1 


2 

4 
4 
20 

4 














1 
































1 




4 
2 




i 






3 






































1 


































1 

3 
1 












o 


















1 

1 














5 












8 
1 
2 
1 
2 






























2 




■| 




1 
1 


















1 










1 


1 






























1 

2 
1 
2 


1 




































2 
3 


1 


































1 




2 
2 
2 
4 

8 


1 








































4 














1 












1 




















1 
1 


i 




















5 
2 












1 






































1 












1 






















1 


2 








3 






1 
1 










































































1 
1 












2 
1 
3 
3 
1 
2 






























1 








2 
5 










1 




1 
3 
10 
5 
1 










































1 
1 












1 
2 
1 






























































1 


































2 
1 








1 








3 
1 
1 
1 


1 




1 


































































1 
1 




















1 














4 








1 


1 
1 


















































1 




























































22 


19 


Total . . . 


1 


,897 




111 


2 


25 


79 


17 


1 


59 


1 


5 


1 


1 


52 


1 


13 




1 


2 


5 


1 


2 


1 
1 


1 


Onnsosi nf rlpntVi 




1 








3 
























1 








1 






















•• 

















1855.] Hammond, Medical Topography of Fort Reading^ Cal. 

thirty-two months, from June, 1852, to January, 1855, inclusive. 



31 



ABSCESS 

AND 
ULCERS. 



"WOUNDS AND INJURIES. 



ALL OTHER DISEASES. 



CO 
O 
O 

o 

a 

o 

s 


m 
p 


6 
<« 

1 


i -2 

5 P 

1 ^ 

• • 1 


; 1 Fractura. 


a 
3 



s ■ 


C 

s • 


a 

3 

3 
B 


. a 

a g 

il 

> t> 


ci 

a 

& 


i 

cS 
J 


1 
S 


P 


3 

p 

g 
P 


; 1 Hemorrhoias. 


= 

c 


\ Odontalgia. 


>i 
c 
o 


i Ophthalmia. 


oo 

Q 


; 1 Scorbutus. 


: 1 Toxicntii. 


><• 


: 1 Morbi varii. i 






1 


1 
1 


































1 
































1 








































1 
1 










4 
4 
1 


1 




1 . 








1 








1 1 




1 


1 
] 














8 
2 

•s 
















1 






























2 


1 












1 


1 




















1 
1 
1 




• 1 




















1 
1 
1 

1 




2 


1 . 












1 

2 
































1 .. 








1 
1 
1 


1 

1 


1 


2 
1 


1 




















1 




2 . . 


































1 




1 








1 
1 


























2 1 


































1 




















1 








































1 

2 
4 






















































1 






















1 








































1 
1 










1 
















1 










































































































1 
















1 


1 


















































1 










1 
























1 




















































1 

2 
2 




1 


2 
1 


1 








4 •• 
1 •• 




1 
1 


1 








2 
1 


1 
1 




















1 






















1 
1 






































2 










1 




























































3 
















































































] 

3 ] 






















li 






\ 6 


29 1 1 




) 1' 


2 1 


3 ] 




I 1. 


) ( 


( 


I 


4 


S 


4 


1 


10 


1 


1 


22 






1 






































1 




1 



































6 I 



1 1 
1 



32 



Bjford, Pliysiolo(jy of Exercise. 



[July 



In point of climate and salubrity, the description of this part of the country 
is applicable to much of the country lying between the range of the Sierra 
Nevada Mountains and the Coast Eange. 

The trihes to which the Indians who rove about here belong, are not dis- 
tinguishable by our present mode of communicating with them. They con- 
sist of a few small bands, speaking different languages, and each known 
specifically by the name of its chief. They are all classed under the term 
digger,^' and are farther arranged according to the names of the streams, 
which are severally their usual haunts. They will average about the medium 
size of white men, and are well-proportioned. The head is not below the 
medium size, and is not deficient in local developments. The superciliary 
ridge projecting unusually, gives the forehead the appearance of retreating- 
more than it would otherwise have. The eyes are not oblique, and the powers 
of vision are very extraordinary ; the cheek-bones are high ; the nose regu- 
larly arched — not long — the alge spread out less than in the African — the 
orifices present downwards ; the teeth are regular, white, not large ; the lips 
are thicker than in the European ; the inferior maxillary bone is not at all 
disproportioned to the rest of the face ; the chest is well developed ; the abdo- 
men is protuberant; the hands and feet are remarkably small; their general 
expression, when not hungry, is that of happiness and benevolence ; at other 
times, they are pensive, grave, subdued, and seemingly loretched. They are 
armed with the bow, made elastic by a layer of some animal fibrous tissue on 
its back, and the wooden arrow pointed with flint. They live on small game, 
fish, insects, acorns, roots, and grass. They dwell in small, round-top huts, 
made of dirt supported by skins and branches of trees. Among themselves, 
and between the different bands, exists a remarkable charity : when starving 
with hunger, they will divide the last morsel of food with all to whom they 
can have access. The men go naked, the women wear an apron of twisted 
grass. When not aggressed upon they are harmless. Poor creatures ! They 
are fast disappearing before the strides of the white man — even his cattle rob 
them of their sustenance. 



Art. Ill— On the Physiology of Exercise. By Wm. H. Byford, M. D., of 
Evansville, Indiana. 

It is seldom that any remedial means receives the importance due to it from 
the great body of the profession, unless its physiological modus operandi is 
rational and well understood. Although the importance of voluntary exercise 
has been recognized for centuries and prescribed to its most useful extent by 
many of the profession, its great practical advantages in a large number of 
diseases have not been appreciated to their full extent by all. The only rea- 



1855.] 



Bjford, Physiology of Exercise. 



33 



son I can ascribe for this is that its effects upon the animal economy have not 
been thoroughly investigated and understood. It is with a view to draw the 
attention of the profession to the importance of more research in this direction, 
that I wish to record my views upon the subject. 

The subject is so extensive and so intimately connected with several other 
questions in physiology, that I shall not attempt to give more than a very brief 
sketch of what I consider the proper physiology of exercise. 

What I mean by exercise is the voluntary discharge of any or all the ani- 
mal functions, as intellect, sensation, locomotion, and voice. The obvious 
phenomena of exercise are, vascular excitement, increased heat, redness of 
the surface, and augmented secretion and excretion. Degrees of voluntary 
functional activity and the number of organs engaged greatly modify the effect 
on the constitution, or, in other words, on the organic functions. Functional 
activity, however, either of the animal or organic system, has the same gene- 
ral effect in accelerating the circulation, promoting secretion, excretion, ka., 
differing in degree, owing to the extent of tissue engaged. For example: 
uncommon activity of digestion (which includes the functional action of several 
organs) increases the circulation, secretion, &c., just as increased activity of 
the muscular system does the same. Languor of function in some of the great 
organs of the organic system produces languor and inactivity of the rest, just 
as inactivity of the muscular system does the same. 

How these phenomena are produced, I shall now attempt to explain. As 
the blood is the fountain from which all organs draw the material necessary 
to supply them in the discharge of their functions (as well as their substance); 
as every organ must be supplied with its own peculiar material, and as the 
materials for the support of all their diverse and separate functions are equally 
distributed throughout the whole mass of circulating fluid, it necessarily fol- 
lows that the supply of blood must be increased in proportion to the increased 
activity of the function of any organ. When the organ is small, and the 
increase in function slight, the supply will take place without any perceptible 
acceleration of the general circulation ; but, if the organ is large, the number 
is great, or the increase of action considerable, then the general acceleration 
of the circulation is essential to the continuance of their vigorous action, in 
order that the material thej^ are expending in the discharge of their function 
may be duly delivered, and the waste material removed. This acceleration is 
not only necessary, but is in all cases the effect of increased function, as may 
be seen by the following reflections. As each muscular fibril contracts in the 
body of a muscle, nutrition and disintegration take place as an accompani- 
ment of that contraction. Nutritive material is taken from the blood, and 
effete matter deposited into it. If the muscle acts slowly, this exchange of 
material between it and the blood is less rapid ] but if by more active volun- 
tary exercise its action is increased, the rapidity of exchange must be increased 
in the same ratio; and as this rapidity of exchange increases, the nutritive 
substance for the sustenance of waste in the capillaries in immediate proximity 



34 



By ford, Pliydology of Exercise. 



[July 



is rapidly exhausted, and the functional action (contraction) of the fibrilla 
would cease but for a continued and abundant supply of unexhausted blood. 
This is readily effected by the elective affinity between the blood in the right 
state for the purpose and the acting tissue ; thus every contraction of the 
fibrilla produces elective affinity in itself for the appropriate nutritive material 
contained in the vessels surrounding it, which draws it forward from the arte- 
rial extremities of the capillaries where the most perfectly elaborated and oxy- 
genated blood is to be found, with a rapidity varying with the quickness and 
frequency of contraction, and after exhausting it of the material necessary for 
its own support, losing the attraction for it, the blood is abandoned to be 
urged forward into the nervous extremities of the capillaries by the stream 
from behind, which is moved by the same elective force. Or, perhaps there 
may also be some real repulsion between the exhausted blood containing effete 
substance from the muscles and the tissues through which it has passed, thus 
gathering a new impetus in an onward direction. 

This is the capillary force of the circulation. If the muscles are acting 
quickly and frequently, they will attract to themselves in this way a large 
amount of blood from the capillaries, and pass it on through the veins to the 
heart. This last organ receiving more than its ordinary suppply, is stimulated 
to increased frequency of pulsation to get rid of the increased amount of blood 
forwarded to it. 

Thus commences and is kept up the vascular excitement of exercise, and 
when a large number of muscles are acting, the general excitement is great. 
Accompanying, and as a consequence of the excitement of exercise, some of 
the organic functions are increased as the excretions and some of the secre- 
tions proper, the former particularly, such as the functions of the skin and 
kidneys. This, no doubt, depends upon the rapid delivery into their capilla- 
ries of the waste materials derived from the acting organs, which is their natural 
stimulus. Hence the perspiration and increased urinary excretion of exer- 
cise. Now, although the above explanation applies particularly to exercise of 
the muscular system, it is to some extent equally true of great activity of the 
nervous system also. And it is not improbable that some of the emotions 
which so intensely excite the circulation, may cause a great part of it by the 
atonic or molecular changes going on in the nervous centres engaged, increas- 
ing the circulation in a large capillary plexus, and thus the general circulation 
as above described. 

It may be objected to this that the effects of many emotional phenomena 
are too instantaneous and intense to be thus explained. After stating that I 
am not prepared to believe implicitly that such is the case, I would reply that 
of course the organic changes going forward in the substance of organs, as 
above explained, correlatively with the discharge of function, must vary in 
the different organs, and perhaps the effects of the muscular system fall short 
of the nervous in celerity and power of action in this respect. Moreover, 
there are but few emotional affections of the nervous system but that calls 



1855.] 



Byford, Phi/siology of Exercise. 



35 



more or less suddenly, extensively, and powerfully into action a portion or 
the whole of the muscular system. I wish to insist here only that immediate 
functional action stimulates the bloodvessels to increased action through the 
capillary system by pouring the blood more rapidly into the heart (not 
merely, perhaps), but for the most part by the atonic change going on in the 
substance of the nervous centres as a necessary accompaniment of their ac- 
tivity, but also the consentaneous and extensive actions of other of voluntary 
or animal organs. 

It has hitherto been generally held, that the mechanical action of the mus- 
cles upon the veins, by pressing forward their contents, is the main cause of 
accelerated circulation in muscular exercise. This theory, however, is cer- 
tainly inadequate to the explanation of the effect of exalted cerebral and other 
fuDctional action in this respect. 

And direct experiment proves that muscular tension alone is sufficient to 
increase the circulation to even a greater extent than alternate contraction 
and relaxation. In the former condition, in fact, they are more intensely 
active than in the latter, and a greater number partake in the function. One 
individual whose pulse, when sitting at ease, was sixty-eight beats to the 
minute, was directed while sitting to stretch one of the lower extremities, 
and retain all its muscles in a state of forcible tension for one minute. This 
increased the frequency of the heart's action to seventy-eight beats. Upon 
maintaining both lower extremities in the same state of tension, the pulse 
was increased to eighty-six in the minute. The first experiment increased 
the heart's action ten beats, the second, eighteen above the natural standard. 
These were repeated in the same individual several times with about the same 
results. They always increased the number of beats very considerably to a 
greater extent in the second than pretty rapid walking. In another person, 
whose pulse was eighty-eight to the minute, when sitting at leisure, the for- 
cible extension of one extremity as above, increased the pulse to one hundred 
and four to the minute, and of both to one hundred and eight. In the first 
sixteen, and the latter twenty beats to the minute above the standard. At 
another time, the first individual held a book weighing three pounds and a 
half at arm's length with the right hand for one minute. His pulse was in- 
creased six beats in the minute. Upon holding one book in each hand in 
the same manner for the same length of time, the pulse was increased four- 
teen beats to the minute. As in all these cases the muscles, although rigid 
and tense, were as near as practicable motionless, the inference is that the 
mechanical effect of pressure could have had but little if any effect in pro- 
ducing the acceleration. 

It must be borne in mind that the muscles of the extremities were not the 
only muscles in action, but that those on the back, hips, and abdomen, in the 
experiments with the lower extremities, and those of the chest, back, and ab- 
domen in the upper, were also in a state of contraction. Of a like character, 
and admitting of the same explanation, is the experiment of standing under a 



86 



Byford, Pliydology of Exercise. 



[July 



heavy load. I think the inevitable inference deducible from the above ex- 
periments, is, that the functional activity of the muscles must have increased 
the circulation, as no other cause was apparent. 

The question will no doubt be asked: "Is this explanation sufficient?" 
The consideration of this question involves the whole of the present received 
theory of the capillary circulation, which, of course, I cannot discuss here, 
but have glanced at above. I think it may be accepted as a demonstrable 
truth, that the alterations in the frequency of the heart's action depend more 
upon the capillary circulation, as influenced by activity of function in organs, 
than any other physiological cause. In fact, the present state of physiology 
and pathology, I think, justifies the conclusion that the activity or inactivity 
of the capillary vessels always influences the heart and arteries, and the latter 
is almost always, if not quite, governed by the former, both in health and 
disease. The more rapidly the blood is transmitted through the capillaries 
into the veins, the more must arrive at the hearty and the larger the quantity 
poured into this organ, the more frequently must it contract in order to pass 
on the accumulating blood. Supposing, as is stated by Volkmann, that the 
combined capillaries of the whole system are in vascular area, four hundred 
times larger than the arteries, and in ordinary activity transmit the blood 
just fast enough to keep the heart steadily beating at sixty-eight in the 
minute ; it is no difficult matter to see how a very slight increase of action in 
one-half of them may, when added to the influence of the other half in their 
natural grade of action, increase the motion of the heart and arteries a few 
beats in the minute, by stimulating them with the additional blood forwarded 
to it. This is precisely what takes place when all the muscles are exercised. 
Probably the whole of the voluntary muscular system does not fall short of 
being equal in weight to all the rest of the organism. Now, if we consider 
that in the experiments with the lower extremities, the blood in one-third of 
the whole of the capillaries (and including the nervous function called into 
play, there must be this much) is passed along for the purpose of supporting 
the increase of nutrition thus demanded, and carrying off the effete material 
from the organs, with but a slight increase of rapidity, we have sufficient 
cause of several additional pulsations to the minute in the heart and arteries. 
But this is not all. The additional amount of carbon in the blood, and the 
demand for oxygen would quicken the motion of the blood through the capil- 
laries in the lungs, and the additional amount of material for other excretions 
would, on the general principles of capillary circulation, accelerate the motion 
of the blood through the other excretory organs into the heart and arteries.; 
and thus it is that a larger portion of blood than usual is carried through the 
capillaries of one-half of the capillary system ; and unless the frequency of 
the heart's action is increased, there must be an accumulation in this organ. 

When mathematically calculated, I apprehend that, viewed in this light, the 
power in the capillary circulation would be found to exceed that of the heart 
and arteries; and, could it be possible, to increase the functional action of all 



I 



1855.] 'B'^hvdij Physiology of Exercise. 37 

the organs to their utmost extent, at the same time that the heart would be 
unable to bear a sufficient part in the circulation to keep it up. For although 
the power of a few capillaries amounts to very little, yet multiply it by mil- 
lions, and the sum would be considerable. We find, in fact, that when the 
walls of the heart are thinned ^by dilatation, or rendered fragile by osseous 
deposition, severe muscular exertion, or a sudden burst of passion causes it to 
give way — to break. This may occur under the increased action of a small 
part of the organism, and it is altogether probable that there is sufficient 
energy in the combined action of all the capillaries to break a sound heart. 

Exercise produces effects varying according to its degree, character, and 
duration, upon the composition of the blood, the secretions, and the solid tis- 
sues themselves. Exercise of the whole of the voluntary muscular system is 
attended with general and equal distribution of the blood, and temperature 
of the body. The regular or exalted action of the whole of the muscular 
system requires efficient distribution of the blood in the extremities for the 
support of themselves under exertion, and by these very wants draw a large 
amount of blood through their capillary vessels in the manner above explained, 
and being distributed all over the system, must thus produce a general and 
equal supply of blood and warmth to the whole body. The active nutrition 
and disintegration thus brought about, and, if exercise is continued, kept up, 
give a degree of comfortable temperature that no artificial heat can produce. 
A very important effect of exercise is its influence on the composition of the 
blood. The doctrine so ably set forth by Paget, in his Surgical Pathology j 
of the necessity of the development of one organ to the right state of the 
blood for the development of another, and that the arrest of the development 
of one would hazard the integrity and efficiency of certain others showing the 
material dependence to a certain extent of all the organs, is no less true than 
that the discharge of function of all the organs in the body affects the capacity, 
by altering the composition of the blood of each other to perform their 
respective functional duties, and that the functional action of each contributes 
to the right " state of the blood," to enable others to perform their duties. 
For wise purposes, this mutual relationship in the higher classes of animals 
between the voluntary and organic system is indispensable. In more respects 
than one, the efficient capacity and action of each are necessary to the support 
and integrity of the other. The procuring food by the animal organs, the 
conversion of it into nutriment, moulding it into the organization, and then 
excreting it by the organic, are all mutually dependent phenomena. They 
are dependent upon each other physically and physiologically. They were 
made to perform for each other those mutual tasks. 

The processes by which the composition of the blood is affected during 
functional action are not certainly known, but the general principles by 
which they are governed are becoming perceptible in the physiology of the 
present day. Although there is great similarity in the composition of many 
organs, there is a peculiarity in the appearance and composition of each 



38 



Bjford, Physiology of Exercise. 



[July 



•wiiich will chemically, physically, and physiologically distinguish it from 
every other, and which recjuires a peculiarity to some extent in the substances 
intended for the support of them separately. And, as all this variety of 
material comes from the blood, vre can appreciate in a general way the effect 
upon the composition of this fluid, the abstraction of a certain material by 
one organ, and again, a different one by another. It is also apparent that 
the failure of a large organ, or set of organs, to withdraw from the blood the 
substance intended for its or their use in the discharge of their functions; and 
there should be no other way of getting rid of it, that its accumulation might 
and most likely would embarrass the functions of some or all the others, 
besides producing disease in other ways. This observation will have more 
force, when it is recollected that, although nearly, if not quite, all the mate- 
rial for the support of the organs in the discharge of their functions, may be 
found in the blood; they do not exist in precisely the same condition, and 
require to be submitted to the elective afiinity of the tissue they are intended 
to support, in order to undergo the necessary alterations; so that, in the 
blood, we may have the materials for the composition of two or three different 
organs in the same Nood-cowijound, the initiative analysis of which must 
begin in a certain organ or not at all. 

The most important of all the organs in the body in this respect, because 
of such large volume when taken together, the most active in their operations, 
or should be, and requiring for their nourishment a network of capillary vessels 
a hundred and fifty times larger in volume when computed together than all 
the arterial system — is the muscular system of organs. The active, continued, 
and judicious use of them in discharging their functions, induces more essen- 
tial and material changes in the composition of the blood in a direct and in- 
direct manner, take more initiative steps in the elimination of an abundant 
class of compounds in the blood, which to be sure have been considered in- 
nocuous, but where accumulated to an improper extent give origin to some of 
the most fatal diseases, than any other class of organs in the whole animal 
economy. Of course we must take into consideration the associate changes 
induced in the blood by the evolution of the nervous energy required to 
actuate them as an important correlative circumstance. I allude to the albu- 
minous or protein compounds. They exist in the blood in larger Cjuantities 
than any other substances. Although many other organs are formed out of 
this ingredient of the blood, and their functions supported by it, the muscles 
seem to be almost exclusively supported from albumen. Taking into con- 
sideration the great extent, therefore, of this system, and the rapidity with 
which it converts albumen into its own composition, and again eliminates it 
by presenting it to the kidneys in a form readily convertible into urea — and 
the albuminous excretion from the skin under a state of exercise, the effects 
of active exertion of the whole voluntary muscular system assume an import- 
ance not easily overrated and not hitherto awarded to it. More than half of 
the albumen of the blood must most likely be consumed by the muscles, and 



1855.] Byford, Physiology of Exercise. 39 



thus eliminated from the bloodvessels per vias naturales, when this system is 
exercised to its intended natural degree. 

When exercise of the voluntary system is carried to an undue extent by 
consuming faster than the powers of digestion, or the vessels of food can re- 
produce the albuminous portion of the blood, it affects that fluid and through 
it the vital organs in an injurious manner. If the solid contents of the serum 
is in this manner reduced, and it is rendered thinner and of less specific 
gravity than natural, it induces anemia by swelling up, and finally bursting 
many of the red corpuscles of the blood, upon the recognized principles of en- 
dosmosis and exosmosis, whereby a thinner surrounding fluid will permeate 
the walls of cells contained in it and cause them to burst. On the contrary, 
when, from chronic want of exercise the albumen of the blood is increased, the 
reverse principle will act in the destruction of the red corpuscles by causing 
their contents to exosmose until they shrivel and die. That anemia may be 
brought about in the former way, but few will deny. The last process, however, 
will no doubt be denied by many. For, although an undue increase in the albu- 
men ought to produce these effects, some physiologists believe it to be directly 
consumed in the formation of urea and other nitrogenous compounds excreted 
by the kidneys. It certainly must be imperfectly eliminated in this way in 
persons of very sedentary and inert habits. For, in the absence of exercise, 
the languid condition of the circulation prevents that efficient state of capillary 
circulation through the secreting organs necessary to their energetic action. 
And further, that urea, in this view of the case, must be formed by the kid- 
neys, while it is certainly much more in accordance with the present state of 
physiology to consider excretion the results of organic disintegration, the dis- 
charge of effete material instead of material in a high state of plasticity, and 
advancing instead of retrograding in vitality under functional action. 

This, I think, will soon be found to apply particularly to the formation of 
urea and uric acid. It at least is certain that the former substance is greatly 
increased by muscular exercise, and should be considered, I think, as a mus- 
cular excretion in the qualified manner before expressed. 

In the experiments which prove the increase of urea by an increase of food 
which affords the protein compounds by Lehmann, we are not told whether 
exercise was taken into consideration or not. If there was only a moderate 
amount of exercise, which is probable, the increase material of nutrition for 
muscular substance would most facilitate the passage of the protein compounds 
through the muscles, and thus into the kidneys. 

Some writer states, I believe it is Becquerel, that protracted paraplegia 
brings on albuminous cachexia. And one of the most potent causes of tuber- 
cular cachexia, which I regard as always being attended with an increase of 
albumen — and its effusion in the tissues as the effect of its superabundance — 
is want of exercise and consequent non-consumption of the albumen of the 
blood. One more fact I would bring to mind here which, I think, bears upon 
the subject, and that is that in the organic system of organs ; for the most 



40 



Byford, Physiology of Exercise. 



[July 



part there are two processes going on, between which there should be a dis- 
tinction made'; one is the histogenatic, by which the solid substance of the organ 
is removed and replaced, or simple nutrition, while the other is devoted to the 
elimination of some secretion or product of some kind. This is true of the 
lungs also ; so that, while an organ is excreting the effete materials of one or 
several other organs, its own effete substance is thrown into the circulation to 
be eliminated by some other. Now, in many of these, the albumen of the 
blood is no doubt the form of substance from which this nutrition is carried 
on as well as out of which the histogenesis of secretion takes place. In the 
animal organs, it will be remembered, this nutrition is the cause, or at least 
the necessary accompaniment of their functional phenomena. They do not 
take from the blood anything that is not returned to it again in an altered 
form. That altered form being an approach towards, or an excretory sub- 
stance to be eliminated through some of the secretory or excretory organs, and 
corresponds in this respect (perhaps in no other) with the effete substance 
from other organs in a state of molecular change from functional activity. 

This leads me to the consideration of the effects of exercise on the secretions. 
The competency of the different secretory organs to the entire elimination, or 
so far as necessary to health, being a supposed condition which in the nature 
of things ought to obtain, the amount and character of the secretions must 
vary very much with the quantity and Cjuality of exercise. The different 
excretions being furnished by the effete material set free from the organs in 
use with the material for the elaboration of their product, the excretory organs 
are urged to functional activity corresponding to the rapidity of the circulation 
through their tissues fraught with such substances. And, as before said, these 
conditions are the result of active muscular exercise. The secretions proper and 
secreto-excretions are all equally prompted to a like energy of action. The 
secretion pouring into the alimentary canal from the lips to the anus, which 
form the solvent and menstrua through which the nutritive portion of food 
finds its way into the blood, and the excrementition is carried along down the 
alimentary canal, are all more efficiently evolved under the influence of exer- 
cise. No doubt but the same reasoning as to the cause of increase of these 
secretions will apply as in the cases of excretions. The blood changes wrought 
by exercise present to the organs concerned in their formation the material 
for their characteristic products in an advanced degree of maturation, or pro- 
bably entirely formed, and in quantity correspondent to the amount of exer- 
cise and consequent increased rapidity of circulation through their tissues. 
The effect of all this is greater demand for and capacity to digest food. It is 
this beautiful mutual dependence and reciprocal stimulation, by affording the 
material ready prepared as it were to each other, both in a physiological and 
physical sense, that the health, efficiency, and even integrity of the animal 
and organic are preserved in their proper condition for the support of the 
whole system. 

I may here, I think, pertinently reflect upon the physiological effect of a 



1855.] 



B J ford, Physiology of Exercise. 



41 



failure from any cause whatever of a large part of the voluntary organs to 
perform their functions. If, for instance, the muscular system is constrained 
or kept still by nervous inability, indolence, or any peculiar habits, the parts 
become weak, soft, shrivel, and finally, if carried to a great extent, their pecu- 
liar tissue is lost and replaced by 'the more simple structure. If no extraneous 
aid is afforded to the individual, the organic is not furnished with food, and 
the whole system perishes from starvation ; but, if the services of this part of 
the organism is dispensed with, and the food is procured by others, then may 
be seen those changes going forward which result from the physiological rela- 
tions before mentioned. That portion of the muscular system which has 
ceased to act, as it has become useless, requires less nourishment for support 
than natural. Hence if the same amount of food be taken, indigestion pre- 
vents its introduction into the system, and thus to some extent regulates the 
supply by the demand. The indigestion is itself the result of inefficient cir- 
culation in the secretory tissues, and a want of the " right state of the blood" 
for the production of healthy secretions necessary to efficient digestion, both 
of which conditions depend on want of muscular action or muscular wear and 
tear. A lack of secretions may be seen everywhere. The feces are dry and 
light-coloured ; the urine is deficient in richness of solid material, if not in 
quantity ; the skin is inactive, all of the functions partake of the inactivity of 
the voluntary system ; and if it cannot be restored to something of its former 
activity, permanent ill health is, in a short time, succeeded by death. The 
effect of inactivity of the organic system may be inferred from what we every 
day witness. We have seen that the quickened arrival of blood to the right 
side of the heart caused by the augmented activity of the capillary circulation 
in muscular or other exercise, excites the general circulation, that functional 
activity of the voluntary part of our organism produces energy of circulation 
and enhances excretion. 

There is a condition of the organic functions which also stimulates the 
heart's action and causes general vascular excitement, that this is the only 
analogy between it and voluntary exercise. Supposed secretion and nutrition, 
one or both, occurring either from a condition of the blood or solid tissues, 
obstructs the capillary circulation, and, by damming back the blood upon the 
left side of the heart, stimulates that organ to increased exertion, and as the 
heart is so organized that a stimulus to one part excites the whole, general 
vascular excitement is the result. 

In the case of suppressed secretions, as of the skin, liver, kidneys, partial 
or complete, &c., in fever, the blood is delivered into the capillaries, but the 
entire or partial arrestment of the elective and repulsive forces exercised by 
the function of secretion leaves these vessels passive membranous tubes through 
which the blood must be forced by cardiac and arterial power alone. The 
arrestment of these forces causes the blood to accumulate behind and eventu- 
ally be felt as a stimulus to the heart and arteries, which are actuated 
thereby to increased exertion. Now, in inflammation, much the same thing 



42 Porter, Climate, etc. of Fort Moultrie and Sullivan's Mand. [July 

occurs in the process of nutrition. The mutual elective attraction exerted 
between the blood and the tissue involved in a state of normal nutrition, 
is subverted by the morbid process, and the capillaries are passive mem- 
branous tubes through which the blood is driven with great difficulty. Ac- 
cordingly, we find that when the extent of capillaries involved is small, in- 
creased throbbing is confined to the vessels of the neighbourhood ; but, if 
extensive, no matter where situated, by causing a larger quantity of blood 
to press back upon the heart, it stimulates it to increased action also. 

In proof that this is a true explanation of the phenomena occurring in fever 
and inflammation ; in the first, anything that restores the play of elective 
affinities above mentioned, and consequently the secretions, removes the vas- 
cular excitement ; and in the last, we have only to restore the right state of 
nutrition to get rid of the inflammatory fever. Another circumstance which 
bears upon this point is that in cases of fever, both idiopathic and inflamma- 
tory, the former, in which there is always a larger capillary surface involved, 
muscular exertion is impracticable. Now, although the blood may not be in 
the right state, for want of the depurating influences of excretion, to allow the 
nutritive changes in the muscular system indispensable to exercise, and hence 
render it not only weak but utterly unable to act much, there can be no 
doubt that the distressing state of oppression and languor, under exercise in 
fever, arises from the additional stimulus to the right side of the heart by 
increased capillary action ; for it is quite conformable with observation that 
the capillary inertia in certain organs where functions have been arrested may 
be accompanied with capillary activity in other parts of the system. "What I 
■ mean by capillary activity and inertia, is, that in the first there is elective 
affinity from a discharge of the functions of nutrition and secretion between 
the blood and the tissues through wlj^ich these vessels pass forward the blood 
in aid of, or independent of arterial and cardiac force. In the second, no 
such affinity is exercised, or at least in a minor degree if at all. 



Art. IV. — On the Climate and Salubrity of Fort Moultrie and Sullivan's 
Island, Charleston Harhour, S. C, with Incidental Remarks on the Yelloio 
Fever of the City of Charleston. By John B. Porter, M. D., Surgeon 
U. S. Army. 

Dr. Strobel states, that the yellow fever was transmitted from Charleston 
to Augusta, Savannah, and St. Augustine, Florida, in 1839. He says : — 

The yellow fever made its appearance also in Augusta during 1839. We 
have conversed with several intelligent gentlemen-, who believe most firmly 
that the disease was transmitted to that place from Charleston. It is true that 
they admit there were some cases of fever which occurred early in the season. 



1855.] Porter^ Climate, etc., of Fort Moultrie and Sullivan's Island. 43 

but it -was not until several cases had been transported there from this place 
(Charleston), that it began to assume that particular form.'^ p. 187. 

Let us examine this assertion. Dr. Kobertson, in his Report to the Medi- 
cal Society, presented December 10, 1839, observes: — 

" There were three cases of yellow fever in our city, in the month of July, 
occurring in individuals brought from Charleston, S. C. An Irish woman and 
her daughter arrived from Charleston on the 27th July — both were unwell on 
the evening of their arrival. One of your committee saw them on the 29th, 
and the mother died, with yellow skin, black vomit, and the other usual symp- 
toms of yellow fever, on the 30th ; and the daughter, who was immediately 
removed to the extreme western part of the city, recovered. These cases 
occurred on the north side of Broad Street, opposite the upper market, and 
were visited by numerous individuals who resided in the neighbourhood. The 
third was a gentleman, who arrived, at the Eagle and Phoenix Hotel, sick, on 
the 31st July. This case was attended by Dr. Cunningham, who states it to 
have borne all the marks of yellow fever, though the patient recovered, without 
either yellow skin or black vomit. Your committee, after minute examination, 
have been unable to ascertain that any other cases were introduced into the 
city, before or since the three just named. 

" The attention of a community is seldom drawn to the existence of an epi- 
demic until its general prevalence, or the mortality, reaches a point sufficient 
to excite general alarm; and hence it is, that the first cases that occur, are 
usually entirely overlooked, or merely considered of a sporadic nature. The 
earlier cases are, also, of a much milder character than those that occur after 
the cause has acquired its maximum degree of virulence. These early cases 
should not, however, be overlooked, as we shall see in the course of our inves- 
tigations, that they form an important link in the chain of cause and effect."' 

It is stated that several severe cases of fever occurred in Mrs. Thomas 
Gardner's family, about the 8th of June, which the committee believed 
" arose from the same cause, though in a less virulent state, that produced 
the prevailing epidemic.^' 

"On the 5th of July, John McGuire, who had labored in the upper ' trash 
wharf,' was taken sick and remained violently ill for ten days. His physician, 
and those who visited him, consider his case one of the same nature as the 
prevailing epidemic. On the same day, a son of Mrs. Bush, who resided nearly 
midway between Lincoln and Houston Streets, on the north side of Broad 
Street, was taken with fever, and died, with yellow skin, and (as his mother 
states) passing from his bowels large quantities of matter resembling coffee 
grounds, on the 14th. She further states that numerous purple blotches ap- 
peared on him soon after his death. His attending physician. Dr. J. A. Eve, 
concurs in the opinion that it was a case bearing the marks of the late epi- 
demic. On the 7th July, a negro named Sophia, was taken sick of fever, at 
the house on Broad Street, next below Augustine Fredericks. On the same 
day, Isaiah Burton was also taken at his residence on the south side of Rey- 
nold Street, just below Centre Street. Both these cases are stated by Dr. Cun- 
ningham to have been decided cases of the prevailing fever. The same phy- 
sician states Mrs. A. Sibley was taken violently ill on the 16th of the same 
month — no other members of the family were attacked until the 25th.^^ 

"Mr. Tutt's daughter was seized on the 14th July, and died, with all the 
marks of the prevailing fever, on the 24th. Mr. Bottom's child, on the south 

^ In the season for endemic and epidemic fevers, the first cases, always termed spo- 
radic, should never be overlooked. These are the most important cases of all, and 
are neglected and forgotten, until some phantom ship comes into port with imported 
contagion, or contingent contagion. The first cases in every summer ought to be 
carefully recorded; and we believe that, in nine epidemic years out of ten, the fever 
has begun before the arrival of the ship which is said to import the contagion. 



44 Porter, Climate, etc., of Fort Moultrie and Sullivan^ s Island. [July 

side of Broad Street, a few doors above the lower market, sickened on the 16th 
of the same month, and died on the 18th. This was pronounced by Dr. Cun- 
ningham, the attending physician, to be a decided and violent case of the pre- 
vailing fever. A negro boy of Mr. Wagner's, on the south side of Broad Street, 
a few doors below the lower market, was attacked with the prevailing fever on 
the 23d July. Henry, a child belonging to Mr. Dalby, on Green Street, just 
above Lincoln Street, was taken with the fever opi the 26th July. Numerous 
other cases, forming a regular connection, could be mentioned, but your com- 
mittee deem those already named quite sufficient. From this time the disease 
became general." 

Here are at least nine (9) cases of yellow fever before the arrival of a 
single case from Charleston. The Augusta cases proper extend from the 5th 
to the 26th of July inclusive, and the first cases of fever from Charleston did 
not arrive until the 27th of the same month, when the disease was already 
epidemic. 

** After having thus given the date of the commencement of the prevailing 
fever, the concurrent testimony of the attending physicians, and the period at 
which the cases of yellow fever were introduced from Charleston, and their 
different localities, we feel satisfied that further argument is unnecessary. 
That the epidemic had commenced, fairly and decidedly, before the introduc- 
tion of a single case of disease from Charleston, must be evident to every un- 
prejudiced observer." 

" Moreover, if the disease had been introduced by contagion, it certainly 
should have been governed, after its introduction, by the same laws that regu- 
late the spread of contagious affections. But, on the contrary, the prevailing 
fever certainly exhibited none of the phenomena that ordinarily accompany 
the spread of contagious diseases. We find it commencing on the same day, 
and almost at the same hour, in different houses, at the time attracting no un- 
usual degree of attention." 

" The fact of a number of persons having been taken with the disease, who 
nursed the sick in what was termed the infected district, has been urged, by 
some, in favor of contagion. As an offset to this, your committee would bring 
forward the fact, that no one was taken with the disease, who nursed the sick, 
who were removed out of the infected district, or to the Sand Hills, or other 
parts of the countty. This we consider an unanswerable argument against 
the contagious nature of the prevailing fever. If the disease was contagious, 
how could a removal of the sick, half a mile or more, from the infected part of 
the city, deprive it of its contagious properties ? On the grounds of contagion 
this cannot be explained ; but, considering the disease of miasmatic origin, the 
fact is easily accounted for. Those who nursed the sick in the infected dis- 
trict, were exposed — and that too at the worst period of the twenty-four hours, 
to the same miasmatic exhalations that had produced the disease in the patient. 
When the patient was removed, however, to an atmosphere free from malarial 
poison, the nurses escaped, though they were exposed to the exhalations from 
the diseased body of the patient, who often expired in the most frightful ago- 
nies, with black vomit, hemorrhage, and all the evidences of extreme putridity. 
Not a single instance can be found, in which an individual, who had not been 
exposed to the contaminated atmosphere of the city, took the disease after 
communicating with those who were removed from tihe city, labouring under 
it, or who took it after their removal. There were instances, in which persons 
slept, night after night, with those who had the disease on the Sand Hills, and 
yet they escaped entirely. Several instances occurred, of persons being 
attacked with the prevailing fever, who had confined themselves to their 
houses, and had neither seen, nor held intercourse whatever with the sick. 
Norris, a criminal, under sentence of death, who was confined in jail, was 
taken with the prevailing fever on the 12th of September, and died on the 10th 
day after his attack, with black vomit and hemorrhage. He was immured in 
a cell ; no person had communicated with him, previous to his attack, but the 



1855.] Porter^ Climate, etc., of Fori Moultrie and Sullivan's Island. 45 



jailer and turnkey, and lie was the first person in the prison iclio took the 
disease." 

" After the first black frost on the 8th of November, great numbers of the 
citizens returned permanently to the city. If the disease had spread by conta- 
gion, why did it not extend to them, from the numerous cases that were then 
under treatment ? These facts are unanswerable, and suf&cient, in the opinion 
of your committee, to convince any reasoning individual that the prevailing 
fever was neither introduced nor spread among us by contagion.^' 

" But again, if the disease was introduced by contagion, whence did it come? 
Charleston is pointed to as the most natural source, as the yellow fever existed 
there at the time the prevailing fever broke out here. We have shown most 
conclusively that the epidemic had commenced before the introduction of a 
single case of fever from Charleston.-" 

"If we examine minutely the history of yellow fever, wherever it has pre- 
vailed, we shall find that it invariably obeys most of the laws which govern 
other miasmatic diseases. It has usually commenced its ravages during the 
heat of summer, increased in violence as the summer advanced, and ceased as 
soon as the temperature ranged below a given point, or after a severe frost. 
Contagious diseases conform to none of these laws. What climate, what tem- 
perature, or what season can arrest the ravages of smallpox, for instance V 

Perhaps it would have been well, if Dr. Strobe! had conversed with the 
intelligent members of the profession in Augusta, as well as with those 
'^intelligent gentlemen." A journey from Charleston to Augusta by rail- 
road is not an arduous undertaking, not so great as the trip to St. Augustine, 
four months after the fever began in Augusta ; and it was as easy for the 
doctor to communicate with Pr. Koberfcson, Chairman of the Committee, as 
it was for Pr. Robertson to address Pr. Geddings. So with the other phy- 
sicians.^ Pr. Strobel's account of this epidemic appears to be erroneous. 
But to the Report. 

"The theory of the second class, who assume the ground that our atmo-^ 
sphere was in a vitiated state, and that the simple introduction of a case im- 
parted an epidemic constitution to this vitiated atmosphere, and thus spread 
the disease, must share the fate of the first. Indeed, if such an occurrence was 
possible — which is contradicted by all the facts connected with the history of 
miasmatic diseases — it will be impossible to account for the introduction and 
spread of the prevailing fever in this manner.^' 

" The principle which vitiated our atmosphere was the cause of the disease ; 
that, without which, the epidemic could have had no existence, and which did 
not require the introduction of foreign cases to produce an explosion. The 
torch had been applied before the introduction of the foreign cases, and was, 
silently and unobserved by the multitude, performing its work of death and 
destruction. Indeed, cases of yellow fever have been brought into our city 
almost every season in which it has prevailed in Charleston, and hitherto we 
hear nothing of their imparting an epidemic constitution to our atmosphere. 
The same can be said of other parts of our State.'^ 

The yellow fever of Augusta, in 1839, was owing wholly to local causes, 
but our limits will permit of only a brief notice of them. The causes pro- 
ceeded from "what is commonly called the Upj)er Trash Wharf, situated 
between Elbert and Lincoln Streets, which we believe to be truly the fons ct 
origo mali." 

A vast quantity of city offal, not less than 200,000 cubic feet of animal 

^ Dr. W. E, Johnson, of xlugusta, wrote to Dr. Strobel.on the subject of transmissi- 
bility, but disagreed with him. 

No. LIX.— July 1855. 4 



46 Porter, Climate^ etc., of Fort Moultrie and SuUwan's Island. [July 



and vegetable matter, had accumulated at this wharf or platform. In April, 
the City Council very unwisely resolved that this immense mass should be 
removed, and the work commenced on the 8th of May, and was partially 
finished on the 29th of the same month. A further levelling was made be- 
tween the 26th of June and 2d of July. 

"During the operation of the workmen on the mass, as they penetrated 
deeper into the interior, tJie heat evolved was so great that they were compelled to 
desist from their vmrk for two hours at a time, so as to suffer it to cool sufficiently 
to enable them to resume their labour, although they wore thick shoes.''' 

After all this levelling and disturbing the mass in midsummer, upwards of 
117,000 cubic feet remained, and the river continuing to fall, portions were 
gradually exposed to the sun which before had been under water. 

"From the 10th of June," says Dr. Robertson, "to the last of August, the 
thermometer in the shade, at 3 o'clock P. M,, ranged from 75° to 96°. The 
dryness of the summer was unparalleled ; at one time there was not even a 
shower of rain for 71 successive days." 

"Mrs. Gardner's is a short distance below the Trash Wharf." Her family 
was attacked about the 8th of June. John McGuire, taken with yellow 
fever on the 5th July, was a labourer engaged on this accumulation. The son 
of Mrs. Bush, taken July 5th, took shelter, from a shower of rain, under the 
platform a few days before. The first cases of the fever from Charleston 
arrived on the 27th of July. 

The physicians of Augusta unanimously adopted the report and resolutions 
submitted with it, the first of which is as follows :-— 

" Resolved, That, &c. — we are of the opinion that the cause of the late epi- 
demic was not introduced into our city, in any manner whatever, from foreign 
sources ; nor do we believe the disease to have exhibited, in the slightest de- 
gree, a contagious nature." 

The second resolution refers to the " Trash Wharf" and the 200,000 cubic 
feet of animal and vegetable matter ; and the third to its entire removal. Dr. 
Robertson's whole report is most interesting. 

Dr. Strobel refers to the report of the " Medical Society of Georgia," on 
the " Origin and Causes of the late Epidemic in Augusta, Georgia," only " to 
express our dissent from their conclusions," without giving a single reason ; 
but he significantly inquires : " How happens it, that the Trash Wharf, and 
the low state of the river, have never before given rise to the disease — for, 
until this season, Augusta has been exempted from its attacks?" p. 188. 

We will tell how it "happens." The report disavows the belief that the 

low state of the river alone produced the fever, for Dr. Robertson says ex- 

pressly, p. 21, that it was not the cause. 

" Again, in 1830, the river was nearly as low as it was during the past sum- 
mer, and the bar on the Georgia side presented about as large a surface for the 
action of the solar heat, and yet our city was never blessed with a greater 
degree of health than during that summer and autumn." 

The Trash Wharf was not in existence in 1830, but was commenced in 

1834, and at a subsequent period was neglected. But the crowning piece of 



1855.] Porter, Climate^ etc., of Fort Moultrie and Sullivan's Island, 47 

folly on the part of the City Council was in disturbing the mass of animal 
and vegetable matter during the heat of summer, in the same way that the 
authorities of Charleston made extensive excavations in 1849, 1852, and we 
may add 1854, and with the same results. 

In 1839, Dr. Strobel carried the yellow fever from Charleston to Augusta, 
then to Savannah, and says that, " finally, in September, we are told of the 
arrival of the Abel family at St. Augustine, from Charleston, and very soon 
after, the disease prevails epidemically in that place.^^ Pp. 148 — 171, 212. 

Now, it so happens that not a single member of the Abel family had yel- 
low fever, common bilious fever, or any illness whatever, sufficiently severe 
to require the attendance of a physician, during the summer and autumn of 
1839, in St. Augustine. It can scarcely be supposed that we would venture 
to say this, if there were not evidence in proof of the assertion, which will be 
produced hereafter ; and we have no hesitation in affirming that, so far were 
the Abels from introducing yellow fever into St. Augustine, there was not a 
single case of it, or of any fever, in the family. 

Dr. Strobel says that yellow fever was carried from Charleston to Savannah 
in 1839. No proof is offered. Dr. Arnold is supposed to know something 
about the fevers of Savannah, and we will hear what he says, October 4, 
1852 

" In 1839, which, like this season, was noted for the unusual quantity of 
fever all over the country, I saw several cases of yellow fever in our city, which 
I considered sporadic, and which were not in sufficient number to entitle it to 
be considered epidemic. Once in every five or six years I meet with a sporadic 
case.'^ 

So much for the importation of yellow fever from Charleston to Augusta, 
Savannah, and St. Augustine, in 1839. 

1843. The fever broke out on Charleston neck, no yellow fever appearing 
in the city proper, or below Boundary (now Calhoun) Street, showing that 
the disease was local, and owing to local causes. Dr. Hume says that this 
epidemic was brought from Havanna by a Mr. E. E. Hughes, whose narrative 
is as follows : — 

*' On the 27th of July, 1843, I arrived in Charleston, in the brig Hague, 
Capt. Trescott, from Havana, suffering under fever. Dr. Simons came on 
board, and was told by Dr. Wurdeman (also a passenger) that no yellow fever 
was on board, he thinking that I had common bilious fever. The day before I 
left Havana, an Englishman, who soon after died, was lying for a few hours 
with a high fever on my mattress. I took him off with much difficulty, as he 
was delirious, rolled up my mattress, and sent it on board the Hague. I think 
I put it in my berth and slept on it during the passage. The mattress went 
with my baggage, and was given to a negro in the house. I was taken to the 
house northwest corner of Wolfe and Meeting Streets, as soon as possible after 
the vessel touched the wharf, where I remained until I recovered, fifteen days 
in bed, and then went to Aiken. The first deaths I heard of in my neighbour- 
hood were two Dutchmen in a small house on the southwest side of Wolfe 
Street, nearly opposite my room." 

This is circumstantial, and let us take the rest from Dr. Hume : — 

** The first case admitted to be yellow fever occurred on the 14th of Septem- 



48 Porter, Climate^ etc., of Fort Moidtrie and Sullivan^ s Island. [July 



her (Dr. Toomer), on the southwest corner of Wolfe and Meeting Streets. The 
cause, of course, was referred to general and local conditions of the climate and 
soil. Heavy showers of rain had fallen at the end of August, and a hot sun 
had succeeded. There were present, perhaps, all the elements to constitute a 
bad atmosphere, such as has previously been engendered in this neighbourhood 
without producing epidemic yellow fever, but the specific modifying agent had 
probably been previously absent, but was present on this occasion, and pro- 
duced the peculiar modification of fever which characterized the season.-'' 

First : Hewes's letter. It does Dr. "Wurdeman injustice. Dr. Wurdeman 
never supposed the man to have "common bilious fever," but lie knew, and 
so stated to Dr. Simons, Port Physician, that there was a man on board wlio 
had been drinking spirituous liquor much too freely, and had delirium tre- 
mens. Dr. Wurdeman never stated that this man, or any other man on board 
the Hague, had " common bilious fever," or any other fever. The man and 
the mattress went to the house, and were given (at least the mattress) to a 
negro, and this mattress, it is supposed, must be regarded as fomites; but we 
bear of no contagion from this source in the house or yard, which ought to 
have been the case if either the man or the mattress was the focus of disease. 
The remainder of Hewes's letter is of little consequence. 

Next : Dr. Hume's statement. According to Dr. Hume, the first case of 
yellow fever occurred on the 14th of September. Dr. TTragg " reports the 
city and suburbs remarkably healthy until the latter part of September. Ac- 
cording to Dr. Wragg's testimony, it was not far from two months after 
Hewes and the mattress arrived before the fever broke out on the Neck ; and, 
according to Dr. Hume, forty-nine days, just seven weeks, elapsed from the 
arrival of Hewes to the first case, on the southwest corner of Wolfe and 
Meeting Streets. As well might the contagion have remained latent and 
smouldering from July to January, or from July to a succeeding July. If the 
period of incubation in yellow fever is seven weeks (forty-nine days), how 
long ought stringent quarantine to be kept up, for each case, in the harbour or 
port of a commercial city ? 

We will refer to the writings of contagionists for opinions in relation to the 
Bulam fever. 

Dr. Stevens says : — 

" The poison which causes the marsh remittent may remain in the system 
even for months before it produces fever; whilst that which is the cause 
of the African typhus (Bulam fever) generally remains dormant about four 
days, but when applied in a less concentrated form, it is often longer than this 
before it paralyses the heart to such a degree as to bring on the cold stage, 
which, in general, precedes the continued reaction.^' — On iJie Blood, p. 219. 

Sir William Pym : " He may be infected by the Bulam fever in a close and 
warm atmosphere, at the distance, perhaps, of several yards : and in an open, 
airy situation, may approach a patient in the same disease, perhaps even to con- 
tact, with very little or no danger.^' 

Sir William Pym says that the Bulam fever is " produced by a specific con- 
tagion, which, when taken into the system, carries on its work of assimilation 
until about the fourth day, when (with high fever) it exerts its influence upon 
the villous coat of the stomach/' &c. — On the Bulam Fever, p. 219. 



1855.] Porter, Climate^ etc.^ of Fort Moultrie and Sullivan's Island. 49 

Dr. Chisliolm, the father of the Bulam fever, uses the following lan- 
guage 

" But whatever were the predisposing causes, the contagion always acted 
within four days from its application to the body. I am aware of the difficulty 
of ascertaining the time which contagion takes to act on the system after its 
admission into it ; but my situation afforded me many opportunities of knowing 
it with sufficient exactness. In some instances, signs of its action have ap- 
peared in six hours ; in others, in twenty hours ; in others, in forty-eight ; and 
in others,, not before the expiration of the fourth day ; so that, in general, we 
may consider the space of time required for the production of the disease, con- 
sequent upon the application of contagion, as a trifle short of two days." 
Again : "Although the disease may be in the same house, avoiding the cham- 
ber of the sick prevents infection ; merely entering the chamber of the sick, 
without nearly approaching the diseased person, has never communicated infec- 
tion, &c. * * * * From hence it is evident that the infectious effluvia do 
not extend themselves beyond a limited distance from the person or thing from 
which they are emitted ; and that this distance may be fixed, at the utmost, at 
six or ten ieetJ'—On Bulam Fever, vol. i. pp. 304, 305, 306, 310, 311. 

Here we have the views of the standard contagionists in relation to the 
period of incubation in the Bulam fever, and also of the distance at which 
the contagion acts on the system — about four days for the stage of incuba- 
tion, and ten feet distance, "at the utmost." Meeting is one of the broadest 
and best ventilated streets in all Charleston, being nearly 70 feet (66) wide, 
yet Dr. Hume extends the latent period of this fever to forty-nine days, and 
makes the contagion active, across a well ventilated street, at the distance of 
70 feet. The fever which Dr. Hume describes as being so contagious must 
have been the genuine Bulam fever, imported from the West Indies, for the 
indigenous yellow fever of those islands is never contagious, nor are the 
" sporadic cases'^ of Charleston. This was certainly a malignant and danger- 
ous fever, having a stage of incubation of seven weeks, and being propagated 
across a well-ventilated street to the distance of 70 feet. Even smallpox, the 
most contagious of all diseases so denominated, could scarcely cross Meeting 
Street. 

Heavy rains had fallen, and great heat followed. Not a street in this part 
of the city was paved or drained, and Wolfe, Reid, Mary, Columbus, and 
other streets in the vicinity, were in bad condition, as they always are, in 
regard to sanitary police. The railroad track, parallel with Meeting Street 
and next to it, has been already described as one of the most filthy spots in 
all Charleston. Here was fever, but it did not spread to other parts of the 
city. Here, according to Dr. Hume, imported contagion remained dormant, 
perfectly innocuous, exactly seven weeks; there was no case other than 
Hewes's on board the Hague ; there was not a single case of yellow fever at 
the wharf where she lay ; everything contagious, contingent contagion, the 
man and the mattress, went from the brig and wharf to the northwest corner 
of Wolfe and Meeting Streets ; the fever did not break out in September 
where we would expect, at the northwest corner, but at the southwest ; not a 
single case of the fever occurred, so far as we learn, at the northwest corner ; 
it prevailed in only a small district of the Neck, its ravages being circum- 



50 



Hall; Pulmonary Lesion under Tubercular Diathesis. 



scribed ; and it did not get into the city proper at all, notwithstanding the 
constant intercourse, and that " many who sickened were brought to the city 
and died."^ A more singular account of the origin of a disease has never, 
we venture to say, been heard of, the floating bedding, near St. Augustine, 
1821, as related by Dr. Strobel, not excepted. 

A Charleston physician of reputation, in active practice, whose name would 
gladly be given were we at liberty, gave us the following account : — 

" We, who do not credit that Hewes could introduce the fever into Wolfe 
Street and vicinity in the manner stated, believe the cause to have been (in 
addition to bad drainage and bad police, the intense heat, and the heavy rains) 
the cutting down and removing, in midsummer, a large mound of earth and 
rubbish, which had been allowed to accumulate. The fever was local, much of 
it severe bilious remittent, and no one took the disease, although several sick 
persons were removed to other and more healthy localities in the city." 



Art. Y. — Pulmonary Lesion treated as an event arising in the progress of 
Constitutional Decline under the Tubercular Diathesis. By J. P. Hall, 
M.D., of Glasgow, Kentucky. 

The topics with which I design more especially to deal have reference to 
the events to which tubercular, as distinguished from strumous diathesis, 
gives rise ; but, under the conviction that there is here implied a distinction 
when there does not exist any essential difference, I will occupy a brief space 
in explanation of my peculiar views. But I must content myself with a bare 
statement of conclusions, without adducing the reasonings by which my posi- 
tion is supported. 

To state that the habit or diathesis resulting in the elimination and depo- 
sition of cacoplastic and aplastic products — establishing pulmonary phthisis 
in one case, in another scrofula, and in a third tabes mesenterica or cachexia 
Africana — is identical, would be assuming grounds no broader than could be 
sustained by well-established facts, as I verily believe; yet such a view would 
seem to require qualification. 

The above enumerated morbid states clearly present diversified pathological 
features, and have accordingly been arranged into nosological varieties ; never- 
theless, I regard them as the offspring of a common progenitor. The features 
by which the individuals are ultimately so easily distinguishable, are the result 
of, and determined by predisposition, temperament, manner of life, &c. The 
prevailing diathesis or dyscrasia constitutes a general disposition to disease, 
which the local manifestation or the peculiar tissue which may become the 
seat of structural lesion, in the progress of constitutional disorder, indicates 
the proximate pathological distinction. 



^ Dr. Simons, 



1856.] Hall, Pulmonary Lesion under Tubercular Diathesis. 51 

From tlie remotest dawnings of medical philosophy up to the period when 
theories are shaped by the teachings of men of our own day, struma, phthisis, 
and other allied diseases have been, in some sort, treated of as bearing a cer- 
tain relation to a pre-existing state of constitutional depravity. Cachectic 
habit, strumous diathesis, tubercular predisposition, &c., are the designating 
terms that have been employed, according as the incipient indications were 
to develop one or another of the definite forms of resultant structural disease. 

In all of this there is an inherently distinct and dissimilar morbid element 
implied, capable of exercising a specific control over the events of disease, 
independently of constitutional idiosyncrasy. Now, to my mind, the propo- 
sition resolves itself into this : that, prior to the development of that assem- 
blage of morbid phenomena, expressive of a local lesion and susceptible of a 
distinctive appellation, as tubercular consumption, scrofula, &c., there is not a 
vitiating agent at work endowed with peculiar and intrinsically dissimilar 
properties, but that diversities inherent in the economy and the peculiar in- 
fluences brought to bear in the individual instance must essentially determine 
the specific character of the final disease. 

I will now proceed to a consideration of that peculiar perversion of the 
nutritive functions resulting in tubercular degeneration of the pulmonary 
structure — regarding the pulmonary implication as merely constituting a 
prominent event, although usually a fatal event, in the progress of the general 
morbid actions. 

We are not accustomed to witness that group of morbid phenomena, ex- 
hibited upon the supervention of material change in the pulmonary structure, 
constituting true phthisis pulmonalis, developed independently of a prior de- 
parture from health ; yet, until signs and symptoms have demonstrated the 
existence of such structural lesion, we are taught not to recognize an instance 
of absolute disease, but rather a negative condition of health. 

The doctrine to which I hold, and upon which I am obstinately inclined to 
act, is, that the organic implication is only a local event, developed in the 
progress of a series of general morbid actions, and to subserve a salutary end. 
But in order correctly to appreciate those laws, to the operation of which the 
dissolution of tissue is due, they must be studied in connection with pheno- 
mena displayed in the processes going forward in the sources which originate 
organized tissues. 

According to the most generally received physiological doctrines, the ulti- 
mate structure of the animal tissues consists in minute cell-formations and 
cell-germs ; that these primordial cells and nuclei are capable of reproduction 
so long as they are supplied from the blood with appropriate organizable ma- 
terials ) the plastic elements of this fluid being resolved into nucleated cells 
also. When the entire group of organic functions are so perfectly performed 
as to place the animal body in a thoroughly normal condition, there is a per- 
petual disintegration and reproduction of cell-structures ; while one process of 
the economy destroys another repairs, so that as long as this state of healthful 



52 Hall; Pulmonary Lesion under Tubercular Diathesis. [July 

integrity obtains there can take place no material diminution of the original 
cell supplies, but any interference to the functions of nutrition must necessa- 
rily arrest their production, and, as the process of disintegration is still going 
forward, the result cannot be otherwise than a rapid waste of tissue. 

Hence the primary forms assumed in the processes of developing solid animal 
tissue are traceable to a sanguiferous source, thereby assigning to the circulat- 
ing current an instrumentality of such essential importance, that without it 
vital changes must at once stop, and vital phenomena cease to be displayed. 
The blood, then, is the universal pabulum vit^, the grand source of formative 
supply for the fashioning of the epithelium cilia to the formation of those 
intricate structures whose exercise gives rise to the complex phenomena of 
voluntary motion and thought; while from the same source are drawn materials 
for continued structural maintenance. 

But that the purposes of normal organization be answered, a completely 
balanced set of machinery is requisite, as well as a due supply of assimilative 
materials ; the latter, by the exercise of the former, to be elaborated and con- 
verted into those primary tissues whose aggregation forms a complete organ- 
ism, 

A set of organs otherwise capable of the most complete assimilative integ- 
rity, without appropriate organizable elements subjected to their elaborating 
functions, and the formative process, must prove an abortion, no less than 
would be the case on the other hand with a due supply of the materials of 
nourishment in the absence of functional apparatus adequate to the changes 
to be consummated in assuming the forms and properties of vital tissue. For 
an organism, after being placed in circumstances every way conducive to its 
physiological welfare, to maintain these circumstances implies the exercise of 
very many vital as well as physical forces ; but to particularize minutely 
would be foreign to my present object. 

The conditions essential to the elaboration of a pure current of vital fluid, 
the changes through which this fluid must pass in view of its adaptation to 
the physiological wants of the economy and the pathological modifications of 
which it is susceptible under the multiplicity of morbid influences to which 
it is exposed, constitute elements of prime interest to an inquiry such as we 
are engaged with ; but opportunity permits me to devote, at present, only a 
passing remark to some of them. 

The component elements of the plastic fluid, by which the several corpo- 
real tissues are traversed, and from which they derive their supplies for 
growth and renovation, are supposed to exist in such relations as will best 
fulfil the purposes to be answered in the healthy economy. At a given 
period in the progress of functional events, this equable and perfect relation 
no longer subsists between the sanguiferous elements ; the fibrinous element 
ceases to be duly elaborated, as evinced in the impaired tone and inelasticity 
of the tissues; the abnormally low proportion of red corpuscles gives rise to 
pallor and other indications of a general state of asthenia. 



1855.] Hall; Pulmonary Lesion under TuherciiJar Diathesis. 53 

The rich materials of nutrition formerly abounding in the vital fluid are no 
longer retained; the cell-germ^ which was formerly conveyed to the remote 
tissue and deposited as the nucleus of a plastic structure, has been replaced 
by the degraded element, susceptible of no higher organization than the ca- 
coplastic and aplastic product. -The ordinary nutritive process has under- 
gone a complete metamorphosis ; the plasticity of the blood has degenerated 
into dyscrasia; and the plastic forces, instead of their wonted compliance 
with the laws of normal organization, are now addicted to flagrant vices. If 
we consider how prejudicial to the vital apparatus must be the efi"ects exerted 
through the blood, thus vitiated, conveying to the remotest recesses of the 
organism extraneous materials of a highly offensive character, we may readily 
perceive how absolutely indispensable to the continued operations of the 
economy is the office to which nature has doomed the lungs, or it may be a 
less vital organ. The economy sustains not only a negative injury in the 
arrest of plastic forces growing out of a deficiency of organizable constituents, 
but the positive evils resulting from noxious elements present, demand their 
speedy withdrawal, and the organ or organs evincing the greatest proclivity 
to ^participate in the progressing decay become a receptacle for the effete 
deposit. 

As would, d priorij be expected, the great depurating organs, the lungs, 
seldom fail to become the chief instruments in the process of ridding the sys- 
tem of the excrementitious materials we have described. And if we reflect 
how vitally dependent upon the integrity of the pulmonary function is the 
adequate preparation of the blood for the uses which it is destined to serve in 
the economy, we are at once prepared for the series of perverted actions and 
torpid functions made manifest. The abnormal elements which give rise to 
the blood-dyscrasia finding efiicient emunctories in the lungs, the vitalizing 
functions of these organs become impaired in consequence of the impediment 
offered to respiration by the amorphous deposit, which, by still further de- 
praving the quality of the nutritive current, accelerates the elimination of 
plastic elements, thereby redoubling the burthen of the emunctories, either 
disposition reacting upon and aggravating the other, or alternately becoming 
cause and effect, until the elaborating power is paralyzed, and molecular 
nutrition permanently arrested. 

The proximate element of disease in the peculiar constitutional habit cha- 
racterized as tubercular diathesis, under which the functions of the body are 
so extensively involved in deviations from their wonted exercise in health, 
consists in the transformation of plastic blood into a fluid not only notably 
deficient in organizable constituents, but prone to the elimination of products 
in the highest degree embarrassing to the operations of the vital apparatus. 
Those materials so essential to the maintenance of a perpetually changing 
mechanism are not merely withheld, but the blood has become the medium 
of bringing into contact with the delicate tissues ingredients directly sub- 
versive of physiological relations, and capable of eff'ecting the dissolution of 



54 



Hallj Piumonarij Le&ion under TuhercvJar Diatliesh. 



[July 



existing tissues. Such organ as may predominate in selective affinity for the 
degraded element becomes a scavenger for the depraved circulation; affording 
a receptacle of deposit for the eliminated tuberculous matter. 

Although it may seem a melancholy alternative, yet the organic lesion is 
an event of absolute necessity ; an event salutary in its design, but direful in 
its consequences. In the progress of a pre-existing constitutional malady 
there has been created an office, associated with which are duties the per- 
formance of which involves the self-sacrifice of whatever organ assumes them, 
yet they must be performed, else speedier and more certainly fatal results 
ensue. Should this fatal service have been assumed by the pulmonary 
organs, as by far most frequently happens, upon the lapse of a period of un- 
certain duration, the function of these organs becomes manifestly impeded; 
the work so extensively involving the welfare of the body, even its exist-^ce, 
ceases to be adequately performed ; efforts are now provoked for the expul- 
sion of the accumulating burthen, audit is expelled; but alas! the source 
from whence the deposit is supplied yields with continually increasing lavish- 
ness. The materies rnorli, which could not, with impunity, be retained, dif- 
fused throughout the circulating current, must prove a canker to the reservoir 
upon which it is concentrated ; and at last nature's provision, which for a 
time held forth the promise of protective relief at least, becomes impotent j 
the lungs decay ; the vital fabric, attenuated and exhausted, succumbs. 

Thus it is that the baud, so gently laid on at first, gradually and insidiously 
but firmly tightens its grasp until the victim is completely crushed. 

The morbid alterations which have been but imperfectly traced clearly 
originate in a lesion of nutrition ; but this lesion does not, in every instance, 
by far, lead to the development of the event which entitles the morbid state 
to the denomination of tubercular consumption. But if the incipient tendency 
does progress to the establishment of the event, or pulmonary lesion, we may 
uniformly, by retracing the steps by which disease has advanced, convict the 
nutritive system of delinquencies, bearing, to the event, the relation of primary 
cause. Xot a single essential morbid change arising in the progress of the 
original diathesis could have been developed independently of this relation. 
Xo process of argumentation could demonstrate to my mind that a tubercle 
was ever formed independently of a prior state of disease. 

A tubercle is an eliminated morbid product, and must of necessity be the 
result of a morbid action engendered by a still further antecedent diseased 
impulse. 

Having already extended this communication beyond the limits originally 
contemplated, I will conclude by offering a few very general reflections as to 
therapeutical relations. 

The first indication is to remove the constitutional disease, or rather correct 
the diathesis ; thereby averting the untoward event which its final progress 
involves, namely, organic lesion of the respiratory apparatus. If this event 
should not have been forestalled, the second step indicated is still to reclaim 



1855.] Hall^ Pulmonary Lesion under Tubercular Diathesis. 



55 



the constitution -from original vices as an absolute condition to the permanent 
arrest and repair of organic lesion. 

The engrossing idea of structural lesion must give place to more extended 
principles of investigation, else therapeutical deductions arrived at can only 
serve to alleviate and retard, while the problem of restoration must remain un- 
solved in reference to the ravages of tubercle. 

Eemedial systems must be predicated upon a broader basis than is afforded 
by stethoscopic disclosures. So far as regards a strictly pathological diagnosis, 
no one has a higher appreciation of the utility of this instrument than 
myself; but when the diagnosis sought is one from which wholesome, sound, 
therapeutical deductions are to be drawn, its value rapidly degenerates into 
inutility. The doctrine that I hold, and which I would inculcate, is, that the 
disease designated pulmonary phthisis does not originate in the pulmonary 
structure ; that the structural lesion here is an event rendered inevitable in 
the progress of a pre-existing morbid habit; and that no process of exploration, 
it matters not with what degree of accuracy the condition of the lungs may 
be revealed, if thus restricted, can materially aid in supplying data for efficient 
remedial procedure. In this I would not be understood to intimate that the 
state of the lungs should be unheeded, or that this accurate method of deter- 
mining what that state is must be discarded; yet such information, for the 
most part, only enables us to estimate the gravity and general import of the 
case, while an expansive field beyond must be scrutinizingly traversed for 
such discoveries as can be made available to the aims of salutary treatment. 

Therapeutical measures must be shaped with the fact constantly in view, 
that the structural lesion is a consecutive event, and that the indications to 
be fulfilled are derived, not from the manifestation of a single organ upon 
which stress has incidentally fallen in the progress of a more general pre- 
existing functional lesion, but the expressions of a morbid organism constitute 
the indications to be sought and obeyed. The process of organization begins 
with the cytoblast, and here it is that the first link is wrought in the chain of 
morbid events, displayed in the progress of those functional and organic 
changes which mark the stages of tubercular consumption from the incipient 
diathesis to the period of its latest ravages. 

There is, probably, no other disease, the history of which furnishes a com- 
mentary upon medical art, more justly humbling to the pride of its votaries 
than the one under consideration. No lengthened argument, no array of 
authentic testimony, is wanting to substantiate the assertion that the present 
state of our science affords no resources worthy to rank as remedies in the 
armory of therapeutical weapons. 

The most judiciously ordered remedial systems which science, wisdom, and 
experience have been capable of devising, have most signally failed in confer- 
ring upon the melancholy victim of consumption the welcome boons which it 
is the mission of the healing art to bestow. When we remember that this 
insufficiency of our art leaves to an undisturbed progress a relentless monster 



56 Casselberry, Physiology of Organic Nervous System. 



whose ravages so fearfully contribute to abbreviate the span of human exist- 
ence, we cannot^ as members of an enlightened and philanthropic profession, 
fail to be impressed with the exalted nature of every effort, the tendency of 
which is to advance us a step in the pathway of useful discovery. The inquiry 
is a noble one, and will conduct the inquirer to a fertile field ; but he must go 
forth prepared to break the surface. 

This article has unavoidably partaken of a discursive character; many 
highly interesting details have been altogether omitted, and those noticed 
have been introduced regardless of system or order ; but if the line of inquiry 
which I have attempted to indicate has been made obvious, more especially if 
the claims which I am persuaded should be allowed it have been in the least 
advanced, my main object has been achieved : for I verily believe, and wil- 
lingly commit to record the opinion, that if in the progress of medical dis- 
covery, the great desideratum — the successful treatment of tubercular con- 
sumption — which has so long and so effectually baffled the champions of the 
noblest science relating to earthborn things should yet be attained, the solu- 
tion of the mysterious problem will not be due to the stethoscope, auscultation, 
or percussion. 



Art. YI. — Inquiry into the Physiology of the Organic Nervous System. 
By Isaac Casselberry, M. D., Evansville, Ind. 

Every material of the universe consists oi.matter in motion. This motion 
is termed force. Heat, light, and electricity are only states of matter. When 
a bar of iron is heated, its molecules are thrown into undulations which are 
propagated with definite form and character to contiguous particles of atmo- 
sj^here, and from them to the hand or thermometer. 

The motions of light, electricity, sound, colour, &c., are entirely analogous 
to those of heat, and the manifestations which they all present are dependent 
on the form of the substance from which they are evolved. 

The causative motions must not be supposed to involve any transference of 
particles from point to point, which is the kind of motion most commonly 
recognized by our senses. There is a wide difference between the motions of 
a wave and the motions of the particles among which it is passing. 

When we disturb the middle of a watery surface, circular waves are pro- 
pagated from the centre to the circumference of the surface. A feather, or 
other light body placed upon the waves, is not drifted forward with them, 
but it remains motionless. We know nothing of matter itself ; all our know- 
ledge of it is confined to its motions. There is no such a thing as a 
vacuum; the term has only a relative import. A substance is heavy or 
light, hot or cold, wet or dry, green or red, according to the form of motions 



i 



1855.] Casselberry, Physiology of Organic Nervous System. 57 



which emanate from it^ and impress our senses. The laws and phenomena 
of motion are^ therefore, the fundamental elements of all inquiry. 

The various motions of matter are not only analogous, hut mutually con- 
vertible. Prof. A. D. Bache has shown conclusively that light may be con- 
verted into heat; colour alone does not modify the radiating power of a 
surface. Expose cloths of the same texture, but of different colours, on a 
surface of snow to the action of sunlight, and the quantity of heat absorbed 
is the same for all the pieces. But the quantity of light absorbed by the 
black cloth is evidently the greatest, because none is reflected; and it is the 
black cloth which always sinks the deepest into the snow. More heat has, 
therefore, gone from the under surface of that cloth into the snow than from 
any of the others, although no more heat was received by it as heat. What 
has become of the light, and where did the increased heat com.e from? 

The light cannot be said to be latent, because by no possible means can it 
ever be reproduced from the cloth. The undulations of light must have 
passed into the cloth, modified by its organic texture, and it was absorbed by 
the snow as undulations of heat. 

The original heat from the sun received increments from each cloth, but 
most of all from that which reflected no light; because all the light passing 
into that one was converted into heat. 

Friction, which is only impeded motion, is productive of all the physical 
forces. When two smooth surfaces are rubbed together, heat is evolved; if 
there be any inequality, electricity is evolved; and if the motion apparently 
lost in resistance be very considerable, light is also generated. Now this 
motion is not lost or annihilated by friction, but it has passed into the forms 
of heat, light, and electricity ; for the quantity of these produced depends 
exactly upon the degree of motive force expended in the friction. 

This theory applied to the facts of caloric evinces the fallacy of the obscure 
doctrine of its latency. Boiling water and steam are always at the same tem- 
perature, 212° F. But steam in being condensed into water gives out 950° F. 
of heat; that is, it requires the mechanical force of 950° F. of heat to con- 
vert water into steam; and, by condensation, this force is again returned to 
its equivalent condition as 950° F. of heat. In the conversion of water into 
steam, the heat is, therefore, changed into mechanical force. 

Heat also produces electricity and chemical actions; and both may be in- 
creased or diminished by the increase or diminution of the caloric, which is 
undergoing the change into these new forms of force. 

Chemical affinity produces heat, light, electricity, magnetism, and me- 
chanical power. This is strongly exemplified in the explosion of gunpowder. 

In all these cases, the amount of new force generated is exactly proportional 
to the rapidity and extent of the chemical action. 

The transmutation of electricity into heat, light, chemical affinity, and me- 
chanical power, is so common and obvious, that philosophers regard that 
agent as the predominant element in nature. While the forms of matter are 



58' Casselberry, PJiysiology of Organic JSfervous System. [July 

continually changing, the matter itself is persistent. None is ever created, 
and none is ever lost. The motions of matter are, however, in a state of in- 
cessant mutual transmutation. Every organized being, vegetable or animal, 
gives back to inorganic matter, not only the material, but the forces which it 
received from it. The forces of nature are motions of matter capable of being 
submitted to mathematical analysis, and mutually convertible into each other. 
The laws by which heat and light are radiated, reflected, absorbed, and polar- 
ized are identical. 

Faraday has demonstrated that the five species of electricity — the common, 
the voltaic, the magnetic, the thermal, and the animal — are identical. That 
great electrician has also demonstrated the identity of electricity and magnet- 
ism, to the entire satisfaction of all philosophers. 

The influence of heat on magnetic bodies, and of light on the vibrations of 
the compass, completes the link of the occult chain which binds all the forces 
or motions together. These facts demonstrate the unity of forces. 

Those physiologists who do not recognize the convertibility of forces have 
been obliged to affirm, that the vital force exists in a dormant condition in 
all matter capable of becoming organized. 

In the lowest form of the vegetable germ-cell, heat and light are required 
as specific stimuli, prior to the commencement of development. The rate and 
extent of development are exactly proportioned to the amount of luminous and 
calorific forces appropriated. 

According to Boussingault, the same annual plant in arriving at its period 
of development, and in going through all the processes of flowering and ma- 
turing its seeds, everywhere receives the same amount of solar light and heat, 
whether it be grown at the equator or in the temperate zone; its whole period 
of growth being in a precisely inverse ratio to the quantity it received in any 
given time, and its rates of growth consequently in a direct ratio. 

Hence, it appears that the organizing force of plants bears a relation of 
equivalence to the light and heat which act upon them. The agency of light 
is particularly directed to the fixation of carbon in the vegetable structure. 
The amount of carbon fixed is always in accordance with the degree of illu- 
mination it receives. The maturation of the seeds of plants, and the eggs of 
insects, may be at pleasure retarded or accelerated by the mere regulation of 
temperature. Dr. Edwards has made some experiments upon the tadpole, 
which show the agency of light in organization. 

When carefully excluded from the sunlight and well supplied with aerated 
water and food, they grow to twice, and even thrice their size as tadpoles. 
But they underwent no change into frogs. Mr. Higginbottom's experiments 
confirm those of Dr. Edwards. According to Dr. Draper, the chemical rajs 
or undulations excite or determine the arrangement of the molecules into 
particular groups, so as to produce developments. The inference from these 
experiments, and a vast mass of similar facts which, might be adduced here, 
is, that the external forces of nature, particularly light and heat, passing into 



1855.] Casselberry, Physiology of Organic Nervous System. 59 

organized structureSj become converted into new manifestations of force, which 
are termed assimilative^ organizing, reproductive, &c. Chemical action and 
mechanical motion constitute the fundamental basis of all these processes. 
By the former an extensive range of new compounds is generated, such as 
have never been imitated in the laboratory of man. Light and heat are the 
forces, which, acting through the vegetable and animal cells as their material 
substratum, produce these new chemical attractions, which determine the for- 
mation of the new compounds. 

In other words, a portion of the force known as heat and light ceases to 
exist as such, and is manifested in a modified form, as chemical affinity, 
which again, in the act of decomposition, is reconverted into heat and light. 

All the external forces are in this manner transformed by the organic 
nervous force into the different organic forces or processes manifested in the 
human organism. 

Vitality in man is produced and maintained by the organic nervous sys- 
tem. The highest production of vitality in any individual, plant, or animal, 
is the production of an organic substance or being, capable of beginning in a 
new individual the wonderful circle of phenomena which characterize the life 
of a parent. There are two incident actions necessary to accomplish this, 
the elaboration of an ovule or organic cell by the female, and the impinging 
upon that cell of another cell, the spermatozoon, secreted by the male. The 
spermatozoon transfers the incipient force to the organic processes of the ovule 
in which it produces a series of transformations of the parent cell, which 
results in embryonic development. 

The spermatozoon is a secretion ; it is vitalized matter in motion. 

As the pollen is the specific form for the embodiment and transference of 
organic force from plant to plant, so is the spermatozoon that of the organic 
nervous force of animals. The spermatozoon presents the anatomical appear- 
ance of a nerve vesicle and its filamentary appendage. It is not improbable 
that the infinitesimal motions going on in its globular portion have the precise 
mathematical character of those which occur in the vesicular, so that not only 
physical peculiarities, but hereditary diseases, are transferred materially from 
parent to offspring. The organic nervous centre is the first tissue formed in 
the embryo. 

Marchesseaux, in his Nouveau Manuel d'Anatomie Generale, says, that, 
at this stage of development, we notice a fact which confirms with irresistible 
power the doctrine of the centrepal succession of organs. Each one of these 
germinating sacks consists of three layers or laminae, differing in nature. Of 
these, the external or serous always begins to organize first ; and from it arise 
successively the spinal cord, brain, vertebra, cranium, the organs of sense, 
and their dependencies. When the external lamina has thus sketched out 
the forms of the organs of animal life, the middle or vascular lamina com- 
mences in its turn, and in a similar manner marks the outlines of the peri- 
pheral vessels, the venae cavae, the aorta^ and the heart. Up to this period, 



60 Casselberry, Physiologi/ of Organic Nervous System. [July 



the internal or mucous lamina has been inactive; but now its movements 
begin, and we see it successively delineate the alimentary canal, the lungs, 
the liver, the spleen, &c. This order is invariable; universally does nature 
proceed in this manner. This is given as a part of the resume of the vast 
embryological researches of Serres and St. Hilaire. 

Prof. Agassiz, in his lectures on comparative embryology, accords with this 
description. 

Ackermann, Rolando, Blumenbach, G-all, and others, state that the solar 
ganglion is the tissue or part first formed in the foetus. What Blumenbach, 
EUiotson, and other physiologists claim for the nisus formativus, is here 
claimed for the solar ganglion, the centre of the organic nervous system. 

Dr. Carpenter, in common with other distinguished physiologists, says, 
that all the phenomena of cell-growth are explicable on the hypothesis of the 
convertibility of forces. 

The more obvious motions of the animal are evidently dependent upon the 
nervous systems. Everything to which the term motion can be applied, in 
man and animals, belongs to the nervous apparatus. Both the voluntary 
and involuntary muscular contractions are a continuation of the organic nerv- 
ous force. The simplest and most universal of these motions are a series of 
cellular transmutations usually known as capillary attraction and ciliary 
motion. These perform an important part in the changes of all organized 
beings. Matteucci has demonstrated them to be chemical attraction. 

Both this attraction and chemical affinity can be shown to be remote modi- 
fications of heat. Capillary attraction can be accelerated or retarded, by 
increasing or diminishing the temperature. The correlation between elec- 
tricity and heat has been demonstrated. Becquerel asserts that electricity is 
a constant attendant upon the phenomena of capillary attraction. Ciliary 
motion, although seldom discovered except with the microscope, is common to 
plants and animals. Nothing seems absolutely indispensable to their activity, 
but the integrity of the epithelial cell to which they are attached. 

Br. Carpenter thinks that this ciliary motion may be a partial expenditure 
of the organic force derived by convertihility from the solar emanations. He 
considers this view to be remarkably confirmed by the fact that, in the his- 
tory of the zoospores of the algae, we have two distinct periods, one of cili- 
ary motion and the other of growth and multiplication. So long as the ciliary 
action continues, no further organic changes take place in them ; but so soon 
as this ceases, and they become stationary, they begin to exercise chemical 
transformations and to grow and multiply as cells. In the higher order of 
living beings, ciliary motion is the expression of the excess of organic force 
in the subjacent tissues. The contraction of involuntary muscles is inde- 
pendent of any connection with the cerebral and the true spinal nervous sys- 
tems. The inherent irritability of muscular fibre, as taught by Haller, is still 
the prevalent doctrine of the schools. But if the mutual convertibility of 
forces has any foundation in nature, this inJierent or latent irritability is as 



1855.] Casselberry, Physiology of Organic Nervous System. 61 

unphilosophical as latent lieat and liglit, or latent force of any other kind. 
The force which produces muscular contractions is not educed from the mus- 
cleSj but it is transferred to them. The cells which constitute muscular 
fibrillae can undergo no modification but shape ; they exercise no power of 
chemical transformation. They undergo no histological changes, and appear 
to be entirely destitute of the power of self-multiplication. The expenditure 
of their organic nervous force in the single act of contraction involves their 
death and disintegration ; their renewal is accomplished by the production of 
new cells- from the myolemma, which itself possesses no contractility. The 
force which produces the contraction of the muscular fibrillse must therefore 
always be transferred to them by the organic nervous branches. It is for the 
conservation of this nervous system that the anatomical and histological tis- 
sues are added to it as embodiments and properties. It is the seat and source 
of their vitality. They are regulated and maintained in co-ordinate life by 
its force. 

Neurine, which is the technical name for nervous matter, is of two kinds, 
the vesicidar and the tuhular. The peculiar power of the nervous system lies 
in the vesicular portion ; it generates force, while the tubular only conducts 
it. Solly and others have aptly compared the vesicular neurine to the secret- 
ing cells of a gland. It eliminates a force from the blood as the nucleated 
cells of the liver or testicles eliminate new and different organic materials 
from the same substance. The tubular neurine has been compared to the 
efferent ducts of the glandular structures, because it is designed to convey 
something from one point to another. The creation of organs in the embryo 
is precisely identical with the nutrition of organs in the adult. The original 
organic cell of the ovule receives the organizing force of the spermatozoon, 
and reproduces from the surrounding amorphous matter, by assimilation, a 
vast number of similar cells with their filamentary appendages of tubular 
neurine. These occupy the points which will afterwards be occupied by the 
various peripheral organs. The cells are provisional centres, and act inde- 
pendently. They eliminate organic nervous force from the maternal blood, 
and construct the tissues at the terminus of their tubes or nerve-trunks, just 
as in the adult body. The growth or extension towards the central axis is 
effected by the successive addition of cells like beads attached to beads ; the 
last bead or cell formed being the provisional centre of the thread, the re- 
maining cells running together by coalescence into tubes, as in the case of the 
arteries. 

Thus each nerve is separately constructed, and they all converge simulta- 
neously towards the solar ganglion, the centre of the organic nervous system. 
They do not, however, reach that axis simultaneously, for they may be im- 
perfectly developed ) the original order of the different formative processes 
may be perverted or suspended, A total arrest of development would give 
us no centres ; it would be death. A partial arrest, however, might give us 
a spinal cord and no brain, or a brain and no spinal cord. The thoracic 
No. LIX.—JuLY 1855. 5 



62 Casselberry, Physiology of Organic Nervous System. [July 

viscera may be imperfectly developedj as evinced in an interesting case pub- 
lished by Prof. Byford. In the remarkable case cited by Dr. Hall of a foetus 
born without either brain or spinal cord^ yet perfectly developed, we have a 
very satisfactory proof of the manner in which the organic nervous system is 
first formed, and of its independence of the cerebral and true spinal nervous 
systems. In the very interesting case of acephalous monstrosity published 
by Mr. Lawrence, in which the brain only was wanting, we learn that all the 
organic and true spinal functions were performed with integrity. The exist- 
ence and function of provisional cells or centres, which disappear entirely 
when their use is fulfilled, are well recognized in general and special physi- 
ology. The motion of the blood begins in the vascular area of the middle 
lamina, some time before the formation of the heart. This motion is from 
the periphery towards the centre, which is afterwards occupied by the heart. 
Nothing so fully and consistently accounts for this motion as the transmuta- 
tion of the organic nervous force from a provisional centre. These provi- 
sional cells are to the capillaries what the cardiac centres are subsequently to 
the heart itself. There can be,'^ says Carpenter, " no reasonable doubt that 
the production of nerve force in the central organs is dependent upon the 
development of the peculiar cells constituting the ganglionic or vesicular 
neurine; and, as already remarked, the progress of physiological inquiry 
seems to justify the belief that either cells or cell-nuclei are agents in the 
origination of nerve-force at the peripheral extremities of the nerve fibre." 
The spermatozoon is a secretion from the testes of the male ; it is organizing 
matter in motion, which is force. This force is communicated to the female 
ovule, which is organizable. An uninterrupted series of cellular formations 
and transformations produced in the organizable matter or force of the ovule 
results in the development of the embryo. When matured, the relation be- 
tween the mother and the embryo, or foetus, is dissolved by the process of 
parturition. The organic functions of the infant retain the organizing force ] 
but the organizable matter is no longer supplied by the maternal blood. It 
must be derived from external sources, and introduced into the infantile 
stomach. 

The organic nervous system may be divided into tJiree series : the first con- 
nects with the nerves of the cephalic domain, whether cerebral or true spinal, 
and passes with them to the muscles and the viscera ; the second plunges 
directly into the viscera; the third embraces the arteries and veins, and forms 
a plexus around their tunics, surrounding and penetrating them to their most 
remote distribution. The cerebral branches of the organic nervous system 
are continuous with the cerebral and true spinal nerves, and must be con- 
sidered as the originators and conductors of all impressions, whether normal 
or abnormal. The organic branches communicate impressions or emotions of 
the mind to the cerebral nerves, by which it is conveyed to the cephalic cen- 
tre, and by reflexed action conveyed back to the tissue or organ first im- 
pressed. They perform a similar function in relation to the true spinal 
/ 



1855.] Casselberrj, Physiology of Organic Nervous System. 63 

system. Every emotion, every sensation, which takes place in the human 
organism, must be attended or preceded by a change of matter or force, pro- 
duced by the organic nervous force. The cerebral nerves can produce no 
sensation, except by means of the cerebral branches of the organic system. 
Neither can the true spinal perform ai!y excito-motory function, except by 
means of the organic branches which are continuous with the inter-communi- 
cations between the cerebral and true spinal nervous systems, and may pro- 
duce a reciprocity of stimulation or debility, by which the functions of either 
one of the three may be increased or diminished. 

The organic system can perform its functions independently of either or 
both the other systems. In support of this may be adduced the well-known 
cases of monstrosity related by Mr. Lawrence and Dr. Hall. In the interest- 
ing case of acephalous monstrosity published by Mr. Lawrence, the brain only 
was wanting ; all the excito-motory functions were duly performed ; it gave 
evidence of pain, and at first moved briskly. The sphincters performed their 
office. This, of course, was referable to the integrity of the true spinal nerves 
generally. The child breathed, and its temperature was natural. It dis- 
charged urine and feces, and took food ] the latter circumstance indicated the 
operation of the functions of the organic nervous system and its collateral 
parts, without any aid from the brain. In the remarkable case cited by Dr. 
Hall, of a foetus born without either brain or spinal cord, yet perfectly deve- 
loped, we have a ver^^ satisfactory proof of the independence of the organic 
functions of the cerebral and true spinal nervous system. 

The fact has been anatomically demonstrated that the solar ganglion, the 
centre of the organic nervous system, is formed before the existence of any 
vascular formation ) that branches of the organic nerve surround and pene- 
trate the coats of the bloodvessels to their most minute ramifications ] and 
that they augment in size and increase in number commensurate with the 
function these vessels are designed to perform in the animal organism. 

The cerebral, the true spinal, and the organic nervous systems, regarded 
separately as the centre of the several nervous systems of man, though exe- 
cuting distinct functions in the economy of life, are, by means of the innu- 
merable ramifications of their subordinate parts, and their union with each 
other, brought into so close a relation that their physiological separation is 
impossible. Though they are not dependent mutually, they, nevertheless, 
exercise such a reciprocity of functions that the health and well-being of man 
are regarded as inseparable from their union. They may be compared to a 
tree, the root, the trunk, and the extremities of which may be said to repre- 
sent them ] for the root has been the source, and continues to be the life of 
the other two ; it existed without them, and might again do so, though dur- 
ing their maturity it fails not to be a recipient of their toil. The root will 
sometimes live without the trunk and its extremities, and so will the para- 
lyzed idiot. The organic nervous system exercises the architectural power 
which is employed in man and in animals to exhibit the wonderful and sue- 



64 Casselberry, Physiology of Organic Nervous System. [July 

cessive changes which characterize not only intra and extra-uterine existence, 
but also normal and abnormal actions. 

The organic functions in the lower class of animals, which have neither 
brain nor spinal marrow, are not less completely performed than the same 
functions in man. Secretion, nutriflon, &c., are as elaborately performed in 
the polypus and oyster as in the mammalia. 

The organizing force derived from the spermatozoon of the male, together 
with the heat and organizable force of the blood of the mother, are subdivided 
into all the organic affinities and molecular motions which occur in the develop- 
ment of the embryo. At birth all the tissues are formed and the blood in 
circulation, and as soon as the lungs absorb the atmosphere the organic nerv- 
ous force becomes the universal and predominant power in the animal or- 
ganism. 

The organic force of the organic nervous system has the same relation to 
the whole organism that the steam has to the several parts of the engine. 
The organizing force and the steam are equally the motive power. To their 
different states must be attributed every kind of change of which the animal 
organism or the machine itself is under any circumstances susceptible. 

The elements of the blood are generated, elaborated, and depurated of their 
effete constituents by a series of cellular formations and transformations by 
the organic nervous force, which manifests itself in the form of affinity, nutri- 
tion, or attraction, by which each nutritive element is attracted by identical 
elements in the elementary composition of the tissue of which it is destined to 
become a component part by cellular formation and coalescence. Every tissue 
of the organism is, in this manner, formed and nourished by its appropriate 
element or elements from the blood. It will be observed that I maintain 
that the blood is formed by the organizing force of the organic nervous system 
derived from the spermatozoon of the male out of the ovule of the female, 
which is organizable; that both of these are secretions; that out of these embryo- 
tic life is developed ; that, when foetal life terminates at maturity by birth, 
the organizable matter is furnished by the food of the infant or adult, which 
is decomposed by the organic force of the organic nerves, and converted into 
a new compound ; that this compound undergoes a series of conversions and 
elaborations by the organizing force of this nervous sj^stem, by which it is 
converted into the various secretions, tissues, and forces of the animal organism; 
and that all these changes of organic matter into living organized matter, or 
into vitality, takes place in the capillary bloodvessels. 

That the functions of all the bloodvessels — arterial, venous, and capillary — 
are generated, controlled, and maintained by the organic nervous system, 
appears evident from the anatomical fact that the solar ganglion, the centre 
of the organic nervous system, is formed before the existence of any vascular 
formation; that branches of the organic nerve surround and penetrate the 
coats of the bloodvessels to their most minute ramifications into the capillary 
system; that these vessels have no other nervous endowment; that the 



1855.] Casselberrj, Physiology of Organic Nervom System. 65 

organic nervous branches augment in size and increase in number commen- 
surate with the function these vessels are designed to perform in the human 
organism, and that this function is independent of that of the cerebral and 
true spinal nervous systems. These nervous systems impart increased 
energy to the organic functions, a^s light, heat, and electricity do to the vege- 
tative. 

Pathology teaches us that the organic processes proceed in those parts of 
the organism in which the cerebral and true spinal nervous systems are para- 
lyzed exactly in the same way as in other parts where these nerves are in a 
normal condition. Sir B. Brodie shows, by his experiments, that the destruc- 
tion of the crural and sciatic nerves, and even the lumbar spinal cord, neither 
retarded nor impaired in any way the reparative processes in the lower ex- 
tremities ; thus, wounds and fractures made in the limbs, deprived of cerebral 
and true spinal nervous influence, healed and united as readily as under all 
ordinary circumstances. The organic nervous branches distributed to the 
extremities were normal, and the organizing force of these branches caused 
the wounds and the fractures to unite. Many other cases in illustration might 
be adduced. 

/Secretion. —The literal meaning of the term secretion is separation. The 
process of secretion is performed by the agency of cells. How complexed so 
ever the structure of a secreting organ, these simple bodies constitute its 
operative parts. The process is strictly analogous to that of nutrition, since 
every cell in the progress of its development forms certain peculiar products 
out of the alimentary materials supplied to it; and just as the cells at the 
extremities of the villi select from the chyme the nutritive portion which is 
to be introduced into the absorbent vessels, so do the cells which line the 
secreting tubuli select from the blood the effete particles which it is their 
peculiar province to assimilate, and discharge them into the canals by which 
they will be carried out of the organism. There are not, therefore, two 
organic processes going on at the same time in the same gland. The only dif- 
ference between this kind of growth and that which occurs in other organs 
is that a portion of the product is thrown out of the organism from the ana- 
tomical condition of the part. There cannot be a better illustration of this 
view than the nature of fat, the production of which is exactly the interme- 
diate link required to connect the two processes. 

The adipose tissue consists of cells, by the action of which the fatty matter 
is elaborated from the blood instead of being thrown out of the organism. It 
remains stored up in their cavities until it is required for use within the 
organism ; and it must then be taken into the circulation by a process resem- 
bling the first absorption of aliment. 

A certain portion of fatty matter is normally formed in the secreting cells 
of the liver, and this quantity may be very much increased, as Mr. Bowman 
has shown, especially in diseases which obstruct the pulmonic circulation. 
The fat elaborated by the cells is destined to be thrown off from the system ; 



66 Casselberrj, Physiology of Organic Xervous System. [July 

and thus we perceive how much the anatomical position of the cells have to 
do with the function of secretion. It can scarcely be Cjuestioned that the chief 
source of the secretion is to be formed in the continued decomposition of the 
various tissues of the organism. They are derived more from the blood itself 
than from the fluids returned into the blood by the lymphatics. During the 
circulation of the bloody it parts with one portion of its constituents in one 
tissue of the organism by the transformation of the cells containing them, and 
with another, in a different tissue by a modification of the same process. The 
abstraction of organizable matter does not occasion any chemical change in 
the composition of the blood, because the fibrin and red corpuscles which are 
thus removed are continuously renewed at the expense of the albumen ; while 
of the albumen, a new supply is absorbed by the absorbent system. The 
elaboration of gelatin, however, which is deposited so carefully in the solid 
tissues, must produce considerable alteration in the blood, since in its produc- 
tion from albumen a certain residuum must be left. This residuum is, pro- 
bably, another source of the products of secretion. In several other instances, 
peculiarities of secretory action in different tissues will deprive the blood which 
passes through them of its due proportion of certain of its elements; these are 
partly restored by its admixture in the heart with the blood which has been 
returned from other parts ; but still a general alteration in the character of 
the blood is the result of its circulation. For this alteration it is the province 
of the secretory functions to compensate. 

A striking illustration may be found in the change of colour, and in the 
proportional amount of free oxygen and carbonic acid, which take place in 
the systemic capillaries by the normal transformations of the cells containing 
the elements of the blood. Hence it may be regarded as a physiological fact 
that no chemical change can be produced in the products of any secretory 
process except by a chemical change in the elementary constituents of the 
blood in that tissue by means of their cellular mutations. Medicinal agents 
must, therefore, induce cellular formations and transformations in the elemen- 
tary constituents of the blood in the capillaries in any gland or tissue, before 
they can chemically change the products of the secretory function of that 
gland or tissue. No therapeutical agent can produce any effect unless it 
chemically alters the elementary composition of the blood. This is the only 
mode by which medicinal agents can act therapeutically. 

The heart is a muscular organ. It is usually regarded as the motive power 
of the circulation. But no physiological fact is more clearly proved than the 
existence in the lower classes of animals, as well as in plants, of some power 
independent of the vis d tergo, by which the circulating fluid in man is caused 
to move through the vessels. This power seems to originate in these ultimate 
tissues, and to be closely connected with the state of the nutritive and secre- 
tory processes, since anything which stimulates them to increased energy 
accelerates the circulation, while any check to them occasions a corresponding 
stagnation. 



1855.] Casselberrjj Physiology/ of Organic Nervous Si/stem. 



67 



For convenience, this motor force may be called organic nutritive attraction. 
The movement of the blood through the capillaries is in a great degree, if 
not entirely, independent of the action of the heart; since it may continue 
after the heart's action may itself cease in particular organs, when the heart 
itself is still acting vigorously;, and it is constantly affected in amount 
and rapidity by causes originating in the part itself, and in no way affecting 
the heart. The movements of the blood in the capillaries of cold-blooded 
animals after complete excision of the heart have been repeatedly observed. 
In warm-blooded animals this cannot be satisfactorily established by experi- 
ments, since the shock occasioned by so severe an operation much sooner 
destroys the organic nervous force. 

After most kinds of natural death, the arterial system is found, after the 
period of a few hours, almost or completely emptied of blood; this is partly 
the effect of the contraction of the arteries themselves ; but the emptying is 
usually more complete than could be thus accounted for, and must, therefore, 
be due to the continuance of the capillary circulation. When death takes 
place suddenly from such a cause as an electric shock, which destroys the 
organic nervous force of the whole organism, the arterial tubes are found to 
contain their due proportion of blood. It has been well ascertained that a 
true process of secretion not unfrequently continues after the cessation of re- 
spiration, and the action of the heart and arteries. Urine and perspiration 
have been secreted, and other peculiar secretions formed in the glands. These 
changes could not have taken place unless the capillary circulation were still 
continuing. In the early embryonic condition of the highest animals, the 
movement of the blood is unquestionably due to some diffused power inde- 
pendent of any central impulsion ; for it may be seen to commence in the 
vascular area before the development of the heart. The first movement of the 
blood is towards the central organ, or heart, instead of from it ; and even for 
some time after the circulation is fairly established, the walls of the heart con- 
sist merely of vesicles loosely attached together, and, therefore, cannot have 
any great contractile power. 

Cases are of no unfrequent occurrence in which the heart is absent during 
the whole of embryonic life. We have described the origin and development 
of the organic nervous force. We have shown that it is created prior to the 
heart, and that it controls and regulates the early embryonic circulation before 
the central organ is formed. It is the formative and controlling force of 
every tissue in the organism. It is to the organism what the steam is to the 
engine. The heart is a muscular organ of wonderful mechanism ; its power 
is derived from the organic nervous system by its organizing force in the pro- 
duction and transformation of the cells upon which the muscular action of the 
heart depends. Without the creation and disintegration of these cells, the 
heart could not act. Its muscular contractions and relaxations are accelerated 
or diminished, weak or strong, in direct proportion to the force of the organic 
nervous system in the mutations of its histological cells. The heart affords 



68 Oasselberryj Physiology of Organic Nervous System. [July 

the organic nervous system the mechanical apparatus necessary for the propul- 
sion of the blood from it into the arterial vessels. There is a constant change 
going on in the cells of which the blood is composed. When the blood is 
carried into the capillaries of the lungs, the cells containing its elementary 
constituents are rapidly formed and transformed. 

The Lungs. — Whatever may be the view entertained of the ultimate struc- 
ture of the lungs, there is no difference in opinion as to the main physiological 
fact that these organs consist of a congeries of minute air-cells, whose cavities 
are capable of dilatation and contraction, and on whose walls a very minute 
plexus of capillary bloodvessels is distributed. The air-cells and air-tubes are 
endowed with a considerable amount of contractility, which resembles that 
of the intestines or arteries, and by which the absorption of oxygen from the 
atmosphere and the secretion of carbonic acid gas from the blood are favoured ) 
because it enables the air-ceils to receive and retain more resident oxygen 
within these cavities, which greatly facilitates the absorption and combination 
of this gas with the carbon of the blood by its continued approximation to and 
gentle pressure upon the minute absorbent cells in the ultimate glandular 
structure of the lungs. The production of cells as an integral part of absorp- 
tion or secretion has been demonstrated by Mr. Goodsir in a variety of expe- 
riments ; and he has further shown that what is ordinarily termed an acinus 
is nothing more than a parent-cell filled with progeny. This statement may 
be applied to the lungs in which the air-tubes do not terminate in a dilated 
sac, but open into a system of communicating beaded canals forming a kind 
of acinus. These beaded canals are evidently composed of cells partly fused 
together; and, by the comparison of their state in animals of different ages, it 
seems that they are all developed from the cell in which the air-tube termi- 
nates, and that they continue to increase in number from the period of their 
birth to adult age. The fact respecting the function of the red corpuscles of 
the blood and their connection with the respiratory function, supplies the re- 
quired proof that respiration takes place through the medium of cells. Respi- 
ration is a process of absorption and of secretion, and governed by the same 
laws by which these processes are in the other glands of the organism. 

Arteries. — Every manifestation of organic nervous force must take place in 
the capillaries. That the movement of the blood through the arterial vessels 
in man is, in a great degree, dependent upon the mechanical action of the 
heart, there can be no doubt. But the bloodvessels have an influence in pro- 
ducing both local and general modifications of the effects of the heart's action. 
The middle or fibrous coat of the arteries is alone endowed with contractile 
properties. The arteries have the same organic nervous endowment as the 
heart. They have vascular and nervous branches of the organic system which 
control and regulate their functions in the organism, and bring them in rela- 
tion to the external world. The fibrous coat of the arteries is endowed with 
muscular branches of the organic nerve, which causes it to contract and relax 
alternately like the walls of the heart, but not in a manner so manifest, 



1855.] Casselberrj, Physiology of Organic Nervous System. 69 



because tlie fibres are shorter, and the organization of the adjacent tissues is 
different. 

The force of these alternate contractions in the fibrous coat of the arteries 
is supplementary to that of the heart's impulse relaxing to receive the blood 
from itj and contracting upon their contents with a power superior to that by 
which they are distended. The muscular coat regulates the diameter of the 
arteries in accordance with the quantity of blood to be conducted through 
them to any organ or tissue. Local changes are continually to be observed in 
the various phases of normal life as well as in diseased states; and they will 
be found to be in harmony with the particular condition of the processes of 
nutrition, secretion, &c., to which the capillary circulation ministers. Of this 
kind, are the enlargement of the trunks of the uterine and mammary arteries 
at the periods of pregnancy and lactation ] the enlargement and strongly in- 
creased pulsations of the radial artery when there is any active inflammation 
in the thumb ; the enormous diameter to which the spermatic artery will attain 
when the testicles is greatly increased in size by diseased action. This dila- 
tion is due to increased nutrition in the coats of the arteries, since we find 
that their walls are thickened as well as distended. 

Capillaries. — We have already indicated the independence of the capillary 
circulation of the heart's action. In an acardiac foetus the heart is never formed, 
yet the organic nervous force manifested in the capillaries in the form of nutri- 
tive attraction supplies its place up to the period of birth, after which the 
circulation ceases for want of due aeration of the blood. The capillaries may, 
by excessive and perverted nutrition, afford a complete check to the circula- 
tion in a part, even when the heart's action is not impaired, and no mechanical 
impediment exists to the transmission of the blood. Thus, cases of sponta- 
neous gangrene of the lower extremities are of no unfrequent occurrence, in 
which the death of the solid tissues is clearly connected with a local decline 
of the circulation ; and an examination of the limb, after its removal, shows 
that both the large tubes and capillaries were completely pervious ; so that the 
cessation of the fiow of blood could not be attributed to any impediment except 
the destruction of some force which existed in the capillaries, and is necessary 
to the maintenance of the current through them. 

Normal reaction between the blood and surrounding medium, whether this 
be air, water, or solid organized tissue, is a condition necessary to the regular 
movement of the blood through the capillaries. When the ordinary respira- 
tion of an animal is interrupted, and the asphyxia is proceeding to the state 
of insensibility, the first lesion induced is that of organic innervation, which 
produces a lesion of circulation, the blood accumulates so as to distend the 
arteries, even though it is at the time nearly venous in its character. This 
indicates that the fluid, now so perverted, is unable to pass with facility 
through the systemic capillaries, be(^use the organic nervous force has lost 
. its controlling influence over the elements of the blood. The elements are not 
normally transformed; oxygen is neither normally absorbed, nor carbon nor- 



70 Casselberry, Physiology of Organic Nervous System. [July 

mally secreted. An accumulation of blood in the venous system, and a defi- 
cient supply of arterial, are the. necessary consequences. When the blood is 
not normally arterialized, it has a depressing influence upon the brain and 
organism generally, because its cells containing its different elements cannot 
undergo normal transformation by which they would form component elements 
of the dijBFerent tissue, or be depurated from the organism. 

It is a general fact, unquestioned by any physiologist, that when there is any 
local excitement to the processes of nutrition, secretion, &c., a determination 
of blood towards the part speedily takes place, and the motion of the blood 
through it is increased in rapidity ) and, although it might be urged that this 
increased determination may not be the effect but the cause of the increased 
local action, such an opinion cannot be sustained. Local determination may 
take place, not only as a part of the regular phenomena of growth and develop- 
ment, as in case of the entire genital system at the period of puberty, but also 
as a consequence of a strictly local cause. All these facts harmonize com- 
pletely with the phenomena which are yet more striking in the lower classes 
of organized beings, and are evidently the result of the same law. The capil- 
laries are endowed with an organization analogous to that of the arteries; they 
appear to be a more delicate and highly organized prolongation of the same 
tissue. That the contractile coat of the capillaries is largely endowed with 
organic nervous branches, which control and regulate their calibres, scarcely 
admits of doubt. Local stimulants produce a contraction of the capillaries by 
their action upon the organic nervous branches distributed into their coats. 
The effect of stimulants is to accelerate the capillary circulation, unless an 
abnormal condition of the organic nervous branches results from their sudden 
or con tinned influence. While the introduction of blood into the capillaries of 
every tissue of the organism is facilitated by the action of the heart, its rate 
of passage through these vessels is generally modified by the degree of activity 
in the processes to which it should be normally subservient in them. The 
current flows more rapidly by an increase in their activity, and becomes stag- 
nated by its depression or total cessation. The capillaries possess a distributive 
power over the blood, regulating the local circulation independently of the 
heart, in obedience to the function of each gland or tissue. The dilatation and 
contraction of the capillaries have only a secondary influence on the move- 
ment of the blood through them j the primary is derived from the organic 
nervous system. 

A gentle stimulant, which excites the contractility of the capillaries, accele- 
rates the motion of the blood by rendering more energetic the cellular formation 
and transformation of its elements, and the combination of its nutritive elements 
with the surrounding tissues. The combination of the nutritive elements with 
the adjacent tissues is in obedience to the laws of organic nutritive attraction, 
and any abnormal influence which imp^jirs this attraction impairs the nutri- 
tion of the tissues in which these capillaries circulate, because it impedes the 
cellular mutations of the elements of the blood upon which the normal nutri- 



1855.] 



Slade^ Incontinence of Urine in CJiildren. 



71 



tive attraction for the surrounding tissues depends. When the elements of 
the blood do not undergo normal mutations, they may be attracted towards 
the solid tissues surrounding the capillaries; but, as they do not undergo that 
series of cellular changes which completely liberates the nutritive elements 
from the effort, they are to some degree repelled by the solid tissues, because 
these tissues attract nutritive elements strictly in obedience to the laws of their 
ultimate elementary composition. Alterations in the chemical condition of 
the blood are, therefore, caused by a lesion of organic innervation, and produce 
a lesion of capillary circulation by which the elements of the blood aggregate 
in obedience to the laws of chemical affinity. This proposition enables us to 
comprehend the magnitude of morbid action produced in the whole organism 
when the lungs fail to absorb a normal quantity of oxygen, or secrete a normal 
quantity of carbonic acid gas ; when the liver fails to secrete normally its 
carbonaceous compounds ; or the kidneys, the effete azotized elements of the 
transformed tissues. When all these depuratory glands at the same time fail 
to perform their normal functions, the blood is soon rendered unfit for the 
purposes of the organism ; a diseased transformation of all the tissues of the 
organism is produced. 



Art. YII. — On Incontinence of Trine in Children. By D. D. Slade, 31. D., 

of Boston. 

Incontinence of urine in children is one of those affections with which the 
practitioner constantly meets, and although in general it is one of no serious 
character, yet it often proves extremely rebellious to all treatment, and be- 
comes exceedingly annoying to the medical man, not only from its obstinate 
persistence, but from the very fact of its apparent insignificance. 

The discharge of the contents of the bladder and rectum take place involun- 
tarily in early infancy; but as the child advances in age it acquires a control 
over the sphincters, being prompted to this by a sense of decency as well as 
by other influences. The involuntary discharge of the contents of the bladder 
may, however, from a variety of causes, be kept up to the age of puberty, and 
even later, proving a source of inconvenience and extreme mortification to the 
unhappy subject of it. 

We shall arrange these children who suffer from incontinence of urine into 
three classes. In the first class, the affection is constant and due to special 
causes which need not occupy our attention here. In the second, it is inter- 
mittent in its character, occurring in the day as well as in the night ; while 
in the third class it is nocturnal only. 

In the second of these classes, which constitute cases by no means rare, 
and much less amenable to treatment than those where the affection is only 



72 



Slade; Incontinence of Urine in Cliildren. 



[July 



nocturnal, tlie urine passes off involuntarily not only during sleep, but also 
during the day, the patient not unfrequently finding his clothes wet without 
having been conscious of having emptied the bladder. Moreover, he is at all 
times obliged to urinate more often than natural, and can scarcely ever resist 
the desire the moment it is felt. This form of incontinence is intermittent, 
the patient at certain periods being almost entirely rid of his complaint. 

It is also, we think, more often found among children of a lymphatic tem- 
perament, and who require a tonic treatment ; and it even appears to be here- 
ditary, as we have seen several members of a family afflicted as were their 
parents before them. This hereditary tendency is also seen in the nocturnal 
form. 

In some of the cases of the above class, the urine is copious, pale-coloured, 
and of low specific gravity, but very frequently neither the quality nor the 
quantity of urine seems to be at fault, but there is a peculiar morbid condition 
of the urinary organs. This condition, as Grross remarks, is undoubtedly due 
to a morbid irritability of the neck of the bladder, to an exaltation of the 
natural sensibility of that part, often unaccompanied by any appreciable change 
of structure. 

It may also depend wholly, or in part, upon sympathy with a diseased con- 
dition of the rectum, vagina, uterus, or kidney. 

The cases coming under the third class do not always constitute a malady, 
properly speaking, but often merely a habit. M. Petit separates children 
suffering with the nocturnal form of incontinence only into three categories. 
The first is made up of those who are too lazy to rise from bed in order to 
satisfy Nature at her first bidding. The second, of those who sleep so soundly 
that the sensation which precedes the desire to urinate is not sufficient to 
awake them ; the neck of the bladder is the only portion which feels, so to 
speak, and which, accustomed to obey this sensation, opens mechanically and 
suffers the urine to pass without the brain being warned. The third, of 
those who dream that they are urinating against a wall, or into a vessel, &c. 

The incontinence of the first and last categories does not depend upon any 
pathological condition of the urinary apparatus, and its treatment consists 
entirely in the adoption of moral means. That which comes under the second 
category is alone to be referred to a morbid condition, and is thus explained 
by M. Barrier, in his Traite Pratique des Maladies de VEnfance. 

^^It is easy to conceive how infancy predisposes so powerfully to nocturnal 
enuresis. At this age the muscular system of organic life enjoys a contracti- 
lity much more pronounced ; all the reservoirs which are provided with this 
are more frequently emptied. Now, the bladder has a muscular coat, the 
contractions of which, at least in part, are under the influence of the ganglionic 
system of nerves, and, therefore, removed from the influence of the will. 
During the day, the effects of these contractions are prevented either by the 
simple tonic force of the constrictor muscles of the neck of the bladder, or by 
their voluntary contraction ) but sleep, which abolishes all voluntary contrac- 
tility, has no such effect upon the sensible organic contractility. 



1855.] 



Slade^ Incontinence of Urine in Children. 



73 



"It wouldj perhaps, be even easy to show that this latter is augmeBted 
during sleep. However it may be, the suppression of the will during sleep 
destroys the equilibrium existing between two powerful antagonists in favour 
of that which naturally predominates in infancy. 

" Sleep also abolishes the functions of sense and of intellect more com- 
pletely than those of instinct, consequently many of these last are performed 
during that state. 

" Other influences also act in a similar manner, such as those dependent 
upon a feeble constitution, upon a lymphatic temperament, and upon inherit- 
ance. As to the occasional causes, it is easy to understand that drinking in 
large quantities, or forgetting to make the child empty the bladder before 
retiring, the warmth of the bed, &c., ought to favour the involuntary emission 
of the urine. 

"A circumstance which tends to keep up this affection, is the habit which 
the bladder soon acquires of emptying itself at certain hours, under the influ- 
ence of the causes of which we have spoken. We know that the frequent 
repetition of the same act contributes to its maintenance by the most trivial 
causes; all our organic functions, as digestion, the excretions, &c., are subject 
to the laws of habit. The influence of habit, then, partially explains the 
obstinate persistence of nocturnal enuresis, which is often prolonged to ado- 
lescence in spite of all remedies. 

M. Civiale difi'ers from most authors as to the cause of nocturnal enuresis 
in children. He remarks that he has observed this condition in subjects 
whose bladders, being in a sluggish state, were continually distended by a 
certain quantity of urine, and that the incontinence here observed is due to a 
veritable overflowing, analogous to that which happens in every form of re- 
tention. 

If such is the cause of this affection, and as frequent a one as M. Civiale 
would lead us to suppose, how does it happen that this overflowing takes place 
only during sleep ? We cannot deny that such a cause may operate in rare 
cases, and the very existence of it should lead us to be very guarded in our 
diagnosis and treatment. 

M. Caudmont, of Paris, has advanced the opinion that incontinence of 
urine in children is often dependent upon what he terms " a contraction of 
the neck of the bladder,'^ comprehending under the term " neck of the blad- 
der," not only the urethro-vesical orifice, but the prostatic and membranous 
portions of the urethra, extending from the above orifice, to the triangular liga- 
ment. The involuntary and permanent contraction of the muscular fibres of 
this part of Guthrie's and Wilson's muscles, gives rise to a variety of symp- 
toms, which are generally described by authors as dependent upon a neuralgia 
or nevrose of this region. To this permanent contraction, or rather to its 
consequences, M. Caudmont attributes incontinence of urine, and accounts for 
the beneficial action of belladonna, of which we shall soon speak, by its power 
of overcoming this condition. 

M. Civiale describes this very contraction in speaking of vesical neu- 
ralgia — 

" The sensibility and contractility of the neck of the bladder being inti- 



74 Slade, Incontinence of Urine in Children. [July 

mately connected, the augmentation of the one ought necessarily to modify 
the other, and thus create trouble in the functions of the bladder. We shall 
see, in fact, when we come to examine the diseases of this organ, that this 
contraction of its neck plays a great part in most of the affections by which it 
is attached." 

We saw, while under M. Caudmont's instruction, sufficient to convince us 
that his views upon this point were very just and well founded ; and, more- 
over, that they were confirmed by his successful mode of treatment. We 
shall^ at some future time, explain more fully this ^' contraction of the neck 
of the bladder,'' and describe its intimate connection with several other com- 
mon and obstinate affections daily presented to the notice of the practitioner, 
the causes of which have been heretofore very obscure. 

We shall not speak here of those specific causes of incontinence of urine, 
such as stone, paralysis, &c., but shall pass on to the treatment of this com- 
plaint. 

If our knowledge respecting the causes of the common forms of enuresis 
in children is thus vague and hypothetical, can we offer anything more satis- 
factory respecting its treatment ? This may be quickly decided. 

First. — Of the treatment of those cases where the incontinence is by day as 
well as by night. The treatment of this form should be general and local. 

The first has for its object to overcome the influence of hereditary disease 
which has a tendency to debilitate the constitution. This end may be best 
brought about by proper attention to diet, which should be plain, and at the 
same time generous and nutritious; exercise in the open air, regulation of the 
bowels, cold bathing if it can be supported, and the use of a proper course of 
tonics. As in this form of incontinence particularly, there is more or less 
morbid irritability of the neck of the bladder, we advise the use of sedatives. 
Any unnatural condition of the urine must, of course, be corrected. 

By the local treatment we propose to modify any undue sensibility or irri- 
tability of the bladder. This comprehends douches of cold water to the sacro- 
lumbar region, the application of blisters to the sacrum and perineum, the 
occasional passage of the bougie, and in extremely obstinate cases even a 
slight cauterization of the neck of the bladder. 

Second. — Of the treatment of those cases where the incontinence is entirely 
nocturnal. As with many children this form of enuresis is cured spontaneously 
towards the age of four or five years, we should be careful not to pursue a 
too active treatment before this age, in endeavouring to overcome what, after 
all, with them is an affection of small importance ) but, when it is proper to in- 
terfere, we must first advise the influence of moral means, which should 
never be harsh or cruel, but just sufficient to awaken the child to a sense of 
shame. 

This has especial reference to those cases where we suppose the trouble to 
be the result of laziness ; if this be the case, we cannot make the habit too 
disagreeable to the individual. What we have already said as regards the 



1855.] Slade, Incontinence of Urine in Children. 75 

general treatment in the other form, is also applicable here. The diet should 
be mild and unirritant. The supper should be taken at an early hour, and 
nothing should be given after this. The child should sleep on a mattress, 
with just sufficient clothing to be perfectly comfortable, and should be aroused 
two or three times, if necessary, in -^order to empty the bladder. Most writers 
speak of the importance of the position to be kept during sleep, viz : upon the 
side, and not upon the back. We agree with Dr. Condie, who remarks that the 
position of the child during sleep is of little or no consequence ; the discharge 
from the bladder taking place, no matter what may be the position. The 
trouble is doubtless often kept up by mere force of habit, and if the particular 
hour can be ascertained when the involuntary discharge takes place, and the 
patient awakened just before the occurrence, and made to empty the bladder, 
he soon acquires the power of retaining his urine during the entire night. 

Sometimes also the affection is due to an irritation produced in the neigh- 
bouring parts by the presence of ascarides. We should always bear this in 
mind in making up our treatment, and direct it accordingly. 

We come now to speak of internal remedies, some of which have received 
high encomiums, without, we think, sufficient grounds. Strychnine and 
cantharides are highly recommended by almost all writers, the latter carried - 
to the extent of producing slight strangury. G-ross speaks favourably of this 
remedy, which he states has succeeded where everything else has failed. 

When any irritability exists about the bladder, copaiba in small doses, and 
cubebs in powder, have lately been highly extolled. Dr. Deiters recommends 
from his own experience, the effects of the latter medicament in tolerably large 
doses given twice a day during a period of from three to eight weeks. A small 
anodyne at night, in the form of a Dover^s powder, often exerts a beneficial 
effect. But it is to belladonna that we wish particularly to call the attention 
of the profession. M. Trousseau has been most instrumental in bringing 
this substance into notice as being applicable to these particular cases of in- 
continence in children, and we can testify to its highly beneficial effects in 
several cases in our own practice, besides those which we observed in the 
Mopital des Enfans Malades. 

The following is from the clinical lectures of M. Trousseau : — ^ 

" This infirmity I consider a neuralgia or nivrose, and it is much more 
common than is generally believed. It has been thought nearly incurable ; 
but, with belladonna, is one of the most easily cured of all diseases. 

■ ^' Those children who are troubled in the daytime are not cured hy hella- 
donna. 

''A child going to bed with an empty bladder will pass his water during the 
first two hours, sometimes during the first hour ; placed in bed at 9 o'clock, 
the bladder will throw off its contents at 10 o'clock, and then retain them 
until 8 o'clock the following morning, being full at that time. The accident 
generally happens once only during the night, but sometimes twice. During 
the first hours of sleep, you generally find in young men and children an 
erection. The question may be asked, whether something of the same kind 
may not take place in the bladder. This complaint is most common among 



76 



Slade, Incontinence of Urine in Children. 



[July 



young girls, and is generally cured spontaneously at the age of puberty ; but 
when this is not the case, do what chance has shown to be efficacious. 

" Two young girls afflicted with hooping-cough were treated with bella- 
donna, and were cured both of the cough and of the affection now under con- 
sideration. 

Treatment. — The first precaution is to break up the bad habit of the organs. 
"Wake the child at the end of an hour, and make him pass his water; after 
several days, make him at the end of an hour and a half. This is only 
accessory. 

^^Grive at the moment of going to bed, ext. belladonna in pill, commencing 
with gr. ], waking the child as has been described. After 8 days, increase 
the dose to double ; at the end of 8 days more, treble it, waking him later and 
later, and finally not at all. When during 15 days he has been free from the 
difficulty, diminish the dose, or give it only every second day, then every third 
day, &c. Even if the child does not regain its bad habits, renew the medi- 
cine after two, three, and sometimes five months' cure, for he may then again 
begin to wet the bed. Resume the medicine as first given, several times, 
making the intervals longer and longer. 

^'The incontinence may be aggravated by eczema, caused by the constant 
irritation of the urine ] and the urethra becoming inflamed, the desire to pass 
water is increased. For this state of things a sol. sulph. zinci is the best 
application. 

''If belladonna fails, try strychnine, flagellation, and stinging with nettles. 
The two latter may be useful as means of intimidation, or perhaps they may 
have some reflex power.'' 

So far as our experience goes, we have derived very satisfactory results 
from the use of belladonna in several cases of nocturnal incontinence. But 
as Trousseau explicitly says, it did not have the same good effects in those 
cases where the enuresis occurred during the day, although it greatly relieved 
the trouble. We have, however, found that a larger dose was required than 
is recommended by that physician, in order to have the desired effect. 

Eeasoning from what we have stated as to the probable causes of this affec- 
tion when it occurs during the day as well as night, we should be led to sup- 
pose that belladonna was even more applicable in this than in the nocturnal 
form only. Practical experience, however, shows that such is not the fact. 

It remains for us to speak of mechanical contrivances for the removal of 
this complaint. The old method of tying the penis is absurd ; but certain 
compressor bandages, such, for instance, as the one which Trousseau recom- 
mends, may be of service when other means have failed. This is composed 
of an elastic band placed about the body, supporting at the back a steel spring 
which reaches to the anus. To this is fitted a metallic plate, on which is 
fixed a truncated cone of India rubber, about two-thirds of an inch in diameter 
at the base. The pressure should be made directly upon the middle line of 
the perineum, and may be regulated by introducing the cone more or less 
deeply. The compression thus acts as a sphincter upon the prostatic portion 
of the urethra. The same beneficial effects may, as Gross remarks, be de- 
rived from the use of a bit of bougie placed along on the under surface of the 
penis, the point projecting a short distance beyond the gland, and retained in 



1855.] 



Nott, Three Surgical Cases. 



77 



its place by strips of adhesive plaster. In this way, the walls of the urethra 
are so approximated that no urine can pass. Of course, it must be removed 
when necessary to empty the bladder. 

For girls, M. Trousseau makes use of an India-rubber bag, which is intro- 
duced beyond the hymen, and by means of a tube inflated with air, which is 
retained by a stopcock. This contrivance presses upon the lower part and 
neck of the bladder, preventing the escape of urine. In the morning, the 
instrument being emptied of air, it is removed or reapplied according to cir- 
cumstances. 

Such are the principal considerations which we have to offer upon this 
bizarre affection. Much is yet left to be discovered as to its causes and 
proper treatment, and this knowledge is only to be gained by long-continued 
and persevering observation. We may hope at some future day to contribute 
the results of our experience towards such a desirable end. 



Art. yill. — Three Surgical Cases. Eeported by J. C. Nott, M.D., 
of Mobile, Alabama. (With a wood-cut.) 

The following cases possess sufficient novelty and practical value to deserve 
publication: — 

Case I. — Spina Bifida cured hy Excision.- — The subject of this case, aged 
one month, was a male, and the child of an Irish woman ; it presented, about 
the middle lumbar vertebra, a tumour an inch and a half in diameter, nearly 
circular, and elevated about three-quarters of an inch. The appearance of the 
tumour was unusual, and the first impression on my mind was that of fungus 
hematodes ; the summit was nearly flat, of a reddish-chocolate colour, and in 
the centre was a thin pellucid membrane of about three-fourths of an inch in 
extent, through which could be seen serous fluid. The most graphic descrip- 
tion I can give of the appearance of the tumour is that it resembled a half 
ripe carbuncle with a Malaga grape buried in the centre ; had it not been for 
this deficiency of skin in the centre I should have been much embarrassed to 
form a diagnosis. Gruided by a case somewhat similar, though smaller, re- 
ported by Dr. Mott, of New York, in his Appendix to Yelpeau, I determined 
to extirpate the entire mass. I accordingly, on the 15th of March, 1855, in 
the presence of Drs. J. Hamilton, Yetchum, and Anderson, and my student, 
Mr. Childs, inclosed the tumour by two elliptical incisions in the direction of 
the spine, and dissected it out completely ; the tumour was found to consist 
simply of skin, cellular tissue, and the membranes of the spine distended with 
serum. After the sac was removed, an opening into the spinal canal was ex- 
No. LIX.— July 1855. 6 



78 



Nott, Three Surgical Cases. 



[July 



posed about the size of the end of the finger, and a tablespoonful of fluid 
escaped. 

It was then dressed by bringing the edges together by a single pin and 
twisted suture, and placing above and below strips of adhesive plaster. 

The dressing was removed on the third day, and complete adhesion had 
taken place by first intention, except the portion included between the pin 
and ligature, which sloughed; this left a narrow gaping ulcer immediately 
over the opening in the spine, and I felt some apprehension about the result. 
I did not reflect on the extreme vascularity and tenderness of the skin of a 
child a month old, and put too much stress on a single point; it would have 
been more scientific to have made a longitudinal cut on each side to free the 
skin, and to have used two pins instead of one. The case, however, did well; 
granulations were thrown out, and the ulcer soon closed, and at the end of two 
weeks the healing was perfect and the parts fijrm and solid. 

The child had no constitutional disturbance whatever ; slept and nursed 
as usual. Two months have now passed, and the cure seems to be complete. 

Case II. — Testicle containing Hair — Removal. — The subject of this case, 
aged 22 years, was a patient of Dr. F. A. Ross, who called me in consultation. 
Says the right testicle was larger than the other in childhood, but never 
painful until the last five years, since which time it has been enlarging, and 
has given a good deal of pain. On examination, a tumour was found larger 
than the fist, about half of which was hydrocele, and the remainder enlarge- 
ment of the testicle ; pus had formed and pointed at the epididymis, but no 
opening had ever occurred. 

It was determined to remove the testicle and sac together, which was done. 
The dissection of the mass after removal revealed the only points of special 
interest. The tunica vaginalis was much thickened, and contained a gill of 
limpid fluid. The testicle itself was enlarged to about four times its normal 
size. On opening it, the tunica albuginea was found a good deal thickened, 
and the glandular contents, if any ever existed, entirely destroyed by suppu- 
ration ; the tunica albuginea was a complete sac, entirely filled with thick pus, 
about the consistence of boiled custard, mixed up with hair, from half an inch 
to four inches long. I sent specimens of the hair to Peter A. Brown, Esq. 
and Prof. Leidy, of Philadelphia, but they could detect nothing on examina- 
tion with the microscope peculiar in the hair, worthy of remark. 

It is more than probable that this development of hair was congenital, and 
I have no speculations to offer on the subject. We have many instances of 
development of hair, in cysts, in various parts of the body ; still, this case is 
interesting both to the physiologist and pathologist, as well as to the surgeon. 

Case III. — Necrosis of Lower Ja w. — The subject of this case was a mulatto 
boy belonging to Major Haden, of Selma, Alabama, about 8 years old. He had 
been kicked by a horse on the lower jaw six months before he was brought to 



1855.] 



Nott, TJiree Surgical Cases. 



79 



me in Mobile, but I could not obtain any satisfactory history of the case. The 
jaw seemed to have been fractured, and when I first saw him there existed 
enormous swelling, with suppuration, and two openings, one at the angle of the 
jaw and the other near the chin. On passing a probe from one opening to the 
other, dead bone was detected. It was determined to make a free opening with 
the view of removing the diseased bone, but the extent of the operation could 
not be determined beforehand. A free opening was made externally down to 
the bone, from the angle of the jaw along its base to the chin ; and, on introduc- 
ing the finger, the body and ramus of the bone were found extensively denuded 
and bathed in pus. The base of the bone was enlarged in thickness to about 
three times its natural dimensions ; and, on passing the finger along the outer 
surface of the bone from the ramus forwards towards the chin, a deep suture 
was felt along the shaft of the bone ; this sulcus seemed to be the line between 
the living and dead bone. The diseased bone was not yet separated at its ante- 
rior extremity, but was still firmly adhering to the sound bone at the chin, 
I dissected loose the soft parts freely, and divided the bone at its anterior part 
with strong bone nippers ; the ligamentous attachments of the condyloid and 
coronoid processes being destroyed by ulceration, I had little difficulty in ex- 
tracting the bone with a pair of large forceps; the whole of the ramus and 
lower half of the body of the bone as far forward as the canine tooth was all 
brought away in a solid piece ; the teeth, alveolar processes, and upper margin 
of bone were all left z'/i sitH. The boy had none but his twenty milk teeth, 
and the interesting point of the case was to see whether the teeth and portion 
of bone left behind could still be nourished and remain healthy after so large 
a piece of bone was removed, including 
the nutritious artery. The subjoined 
wood-cut will give a correct idea of 
the extent of bone removed; which 
is indicated by a dark line. The case 
did well, and was soon sent home to 
the country. 

I received a letter, a few days ago, 
from Dr. Wm. P. Reese, from which 
I give the following extract, dated 
about two months and a half after the 
operation : — 

"I have this day examined the little boy William, of Major Haden ; he is 
quite well with the exception of a very small half closed fistulous opening at 
the anterior terminus of the cicatrix, from which there is very slight exuda- 
tion ; the teeth, gums, and alveoli are hi situ^ and apparently perfectly healthy; 
his general health is good.^^ 

As I had to make an artificial division of the bone at the chin, I expected 
slow healing then, and probably the discharge of some small fragments of 
carious bone. 




80 Learning, Use of the Foramen Soemmering of the Eye. [July 

This case will be a curious one to watch, both in a pathological and physiolo- 
gical point of view. Will such a section of bone be able to sustain itself and 
the inclosed teeth ? will new teeth replace the old ones when cast off? will 
this fragment of jaw have sufficient strength for mastication ? I hope to be 
able to keep a watch upon the case through my friend, Dr. Eeese. 



Abt. IX. — On the Use of the Foramen Soemmering of the Eye. By F. Lea- 
MiNG, M. D., of Tippecanoe Co., Indiana. (With two wood-cuts.) 

Precisely in the axis of the eye there is a yellow spot on the retina, one- 
tenth of an inch in diameter, with a small hole in the centre ; between the 
yellow spot and the optic nerve there is a bifurcated fold of the retina, the 
opening of which is towards the yellow spot. These three marks, viz : the 
yellow spot, the foramen, and fold, are called after Soemmering, their dis- 
coverer; but their uses, so far as I can learn, have not hitherto been ex- 
plained. 

If we close one eye and look upon the page of a book, we shall notice that 
the word in the axis of the eye, as well as the words immediately above and 
below it, are distinct, while the rest of the page is illegible. Perfectly distinct 
vision is confined to a very small space of the retina, and is bounded by the 
limits of the foramen in the centre of the yellow spot. But an opening in 
the retina, instead of perfecting, would destroy vision ; we must necessarily 
conclude that, under the circumstances alluded to, the foramen is closed. 
Now, the foramen has sometimes been found closed by anatomists, but then 
the bifurcated fold had disappeared, and the only mark of its previous exist- 
ence was a dent in the vitreous humour corresponding precisely to the fold. 
An open foramen with a fold of the retina ; a closed foramen, and no fold of 
the retina j all this implies motion of the parts. 

If we look at a distant object with both eyes open, and pass an ordinary 
ruler before one of them so as to exclude the distant object, the central part 
of the ruler will be invisible to that eye ; that is, the central part of the retina 
has become insensible to light. The bounds of this insensibility can easily 
be defined, and they will be found to correspond with those of the yellow spot 
of Soemmering. The following diagram will illustrate this sufficiently, the 
ruler being held about 12 or 15 inches distant, and made to pass before the 
left eye: — 

Fig. 1. Fig. 2. 



1855.] Hays^s Knife-Needle for Operation for Cataract. 



81 



Fig. 1, A, represents the ruler seen by the right eye; B, that by the left; 
the outline of the extremity being faintly visible ; the central part as far as C 
is transparent or invisible, while the distant object appears at D. 

The ruler may now be passed further to the right, when the extremity at 
B will become visible again ; showing that the power of becoming insensible 
to light, under these circumstances, is possessed only by the yellow spot of 
Soemmering, and not by the retina at large. It is curious to watch the play 
of sensibility; sometimes the transparency expanding widely and in a moment 
contracting to a mere point. 

The use of all this is evident. When two objects are presented (a very 
frequent occurrence), one in the axis of each eye, the mind is not perplexed 
by the blending of the two objects, but contemplates the one while the other 
is withdrawn. This may be further illustrated by Wheatstone's Stereoscope. 
Place before the glasses a printed page on which two pencil marks have been 
drawn vertically about two inches apart. Let the lines be thrown into one by 
the action of the eyes, and fix the attention on any word the lines appear to 
run through. At first, perhaps, there will be a blending of letters, so that no 
word can be made out, both foramina being closed and sensitive; presently a 
word will be distinct, and either be retained or alternate with a word through 
which the other pencil mark passes. We may infer that this is owing in the 
latter case to the alternate action of the foramina, and not to the alternate 
action of the eyes, for the vertical pencil marks remain blended. 

I have made other experiments than these on this subject, but as they are 
more difficult, and all result in proving that the central parts of the retina 
have an action independent of the retina at large, and as those already given 
are sufficiently conclusive, I shall detail no more. 



Art. X. — Knife-Needle for the Operation for Cataract hy Solution or 
Absorption. By IsAAC Hays, M. D. 

The operation for the removal of cataract by solution or absorption, has 
been deemed, by many surgeons, entirely inapplicable to hard cataracts, 
mainly in consequence of the difficulty of dividing such a lens by the needle 
ordinarily used for the purpose. The common straight needle cannot be 
made to cut well, beyond a short distance from the point, without being so 
thin as to endanger its breaking ; and it is not possible to cut with a curved 
one. I have entertained the belief for several years, as is well known to 
my friends who are interested in the subject, that a needle better adapted 
for the purpose might be made something after the fashion of an iris knife, 
and more than three years since, I had such a one <constrxiQted by Mr. 



82 Hays's Knife-Needle for Operation for Cataract. [July 

Schmidt. This instrument was described and figured in my last edition 
of Mr. Lawrence's Treatise, p. 726. 

The instrument, not having been made of the exact form I desired, though 
described as having a very acute point, is not so represented in the cut. Not 
being satisfied with the instruments made for me in Philadelphia, I sent a 
model to Messrs. Phillip & Wicker, surgeon instrument makers in London, 
with directions as to the improvement I desired in its form, and an order to 
make me some of them. The instruments which they sent to me were made 
with the point sufficiently acute, but the back was 
17, o. 1 T7,n. 9 straight to the point, and the cutting edge was too long, 

the makers having followed the model of the ordinary iris 
knife too closely. 

A model was afterwards sent to M. Luer, of Paris, 
with an order for some of his make. These, on their 
arrival, I found not sufficiently slender, and the point 
was not sufficiently acute. 

I have since had them made of different shapes, and 
finally Mr. Kolbe, of this city, formerly a workman of 
Mr. Luer, in Paris, has succeeded, under my directions, 
in making me one which has given me entire satisfac- 
tion, and is represented of its natural size in the accom- 
panying cut. Fig. 1. 

This instrument, from the point to the bead near the 
handle (a to 6, see Fig. 2), is six-tenths of an inch, its 
cutting edge (a to c) is nearly four-tenths of an inch. 
The back is straight to near the point, where it is trun- 
cated, so as to make the point stronger, but at the same 
time leaving it very acute ) and the edge of this trun- 
cated portion of the back is made to cut. The remainder 
of the back is simply rounded off. The cutting edge is 
perfectly straight, and is made to cut up to the part 
where the instrument becomes round c. This portion re- 
quires to be carefully constructed, so that as the instru- 
ment enters the eye it shall fill up the incision, and thus 
prevent the escape of the aqueous humour. In the 
diagram (Fig. 2) the proportions of the blade are not 
very accurately represented, the rounded part being 
rather too slender, and the handle should be octagonal, with equal sides, and 
of the same thickness its whole length. 

We have now used the knife-needle in a sufficient number of cases to be 
convinced of its superiority over any of the ordinary cataract needles ] and 
of the different forms of the former which we have tried, the one represented 
in the accompanying drawing is, we are satisfied, the best ; and we confidently 
recommend it as such to ophthalmic surgeons. 




1855.] 



Mitchell; Case of Vicarious Secretion of Milk. 



83 



Art. XI. — A Case of Vicarious Secretion of Milk. 
By S. WiER Mitchell, M. D. 

Instances of vicarious secretion are so rare that the addition of even a 
single case cannot fail to excite interest. It is not uncommon to meet with 
instances of vicarious menstrual flow ] but this secretion, if such it be, is so 
nearly allied to the blood itself as to require no elaboration, and thus, when 
the body is overloaded with blood we can hardly feel surprised at any hemor- 
rhage which, by replacing the uterine flow, relieves the congested vessels.* 

The difficulty of comprehending this subject is greater in cases of vicarious 
performance of the urinary function. Here, we have a secretion for whose 
perfection cell-action is in all likelihood essential. Metastasis of this excretion 
involves, therefore, the existence of such cells in some remote part of the 
body, where nature has not primarily placed them. Their function will be 
one of mere selection, and not of elaboration, since the elements of the urine 
exist, for the most part, preformed in the blood. The mammary gland se- 
cretes a fluid whose elements are not alone separated from the blood, but are 
also elaborated, to a certain extent, as, for example, sugar of milk, which has 
no being in the circulating fluids. The milk-globules, once regarded as true 
cells, are, in reality, globules of oil which have taken on a coating of albu- 
men. Their appearance may be closely imitated by shaking together oil and 
albumen, when similar pseudo-cells are formed. The milk globules, therefore,, 
cannot be regarded as presenting any added obstacle to the metastasis of the 
mammary secretion. 

In the early part of July, 1853, Mrs. C, ast. 20, was delivered of a child. 
The supply of milk proved scanty. Four weeks after delivery, a large mam-- 
mary abscess formed in the left breast. This was opened, and, under treat- 
ment, became well in the course of three months. During this period, sho 
nursed her child with the right breast. As the milk continued to form, though 
in small amount, in the left breast, the child finally obtained milk from both 
mamm^. At the close of a year, the mother became feeble, and subject to 
constant bronchial irritation. Her cough increased to such a degree that,, 
for obvious reasons, she was directed to wean her child. The change was- 
eff"ected too suddenly, and she was told, accordingly, to allow her babe a part,., 
at least, of her own milk. In the interval of two days, the breasts had 
become swollen, and excessively painful. It was now found that the child 
could obtain no nutriment from this source, and that even the pump failed to 

' The most curious case of this kind, of which I am aware, occurred a few years 
ago in the person of a seamstress. The menstrual flow in this instance took place 
with great regularity from beneath the finger nails, and obliged her to relinquish all 
work for a time. She recovered her health by the aid of iron, etc., and the uterus 
resumed its lost function. — S. W. M. 



84 Mitchell, Case of Vicarious Secretion of Milh. [July 

empty the mammse. Purgatives were ordered, and a water-dressing locally 
applied. Next day I found the breasts less painful, while the cough had 
become dry, hard, and almost constant. On the succeeding morning, she was 
greatly relieved by a loose cough, which enabled her to expectorate a quan- 
tity of white, firm sputa. I was told that Mrs. C. was spitting up milk, and 
the white substance in question was exhibited in confirmation of the state- 
ment. During the day, upwards of a teacupful was thus cast up. This 
strange formation continued for a fortnight, to the manifest relief of hitherto 
urgent symptoms of declining health. My visits were made at irregular in- 
tervals, and for a time my patient was closely watched by the family ; but, as 
the secretion was persistent in amount for a time, and as it was often coughed 
up in my presence, I see no reason to suspect collusion or hysterical deception. 
At the end of a fortnight the milky sputa became more pale, and at length 
gave place to mere mucus. 

On the third day, and at intervals afterwards, I collected portions of the 
sputa, and submitted them to rigid examinations. 

I found the discharge to consist of white clots, floating in a thick fluid, also 
of a white hue, and mingled with ordinary mucus. Yery often a clot of yel- 
lowish muco-pus was enveloped in a covering of thickened milk. It is to 
be noted that the milk was, for the most part, in this clotted condition, 
and possessed the lacteal odour to a greater degree than the ordinary secre- 
tion itself. 

Microscopic analysis revealed the presence of very perfect milk globules, 
mingled with compound granular cells, mucous corpuscles, and epithelia. I 
evaporated about one ounce and a half of the fluid, and, by repeated treat- 
ment with ether, collected a small amount of fat or oily matters. Nitric acid 
was found to coagulate the filtered fluid, whilst acetic acid produced but a 
slight cloud. Lastly, I was told by the patient that the sputa tasted like 
milk. 

Mrs. C. was delivered of her second child in February of the present year. 
Her cough never left her, and at the period last alluded to, she was far ad- 
vanced in phthisis. Her breasts were well filled, but her extreme feebleness 
obliged her to resign her child to a wet-nurse. The breasts were artificially 
emptied, aperients employed, and no signs of her former trouble appeared 
until seven days after birth. At this time, for some forty hours, she coughed 
up a thin white fluid, mixed with the pus from a tuberculous cavity in the 
right lung. At the close of the period of time just mentioned, the pulmonary 
sputa regained its colour. I examined this specimen with the microscope only. 
It was thin, and small in quantity, but did not otherwise diflPer from the spe- 
cimens obtained during the last year's illness. Both alike contained milk 
globules. The recurrence of the milky sputa was first observed by me, and 
pointed out to the patient. This, with the other facts above alluded to, in- 
duce me to regard the above stated case as indisputably one of vicarious or 
metastatic secretion of milk. We are thus called upon to admit that some 



1855.] Taylor, Castration; Recovery y followed hy Phthisis Pulmonalis. 85 



part of the bronchial surfaces may repeat the role which nature has assigned 
to the mammary gland. 

It may be as well to add that, in stating a case of interest mainly to the 
physiologist, I have avoided all detail as to the remedial measures employed 
from time to time.^ 



Art. XIT. — Castration ; Recovery, followed hy Phthisis Pidmonalis. 
By Wm. T. Taylor, M. D. 

Charles H., a cigar-maker, residing in this city, was in the habit occa- 
sionally of drinking to excess. He was a married man, and the father of 
three children. In the early part of the year 1853, he had been on a de- 
bauch for several weeks, when he was attacked with mania ci poiu. Being 
unable to sleep, and having his mind constantly disturbed with hallucina- 
tions, he applied to me on March 6th for relief, when I gave him a table- 
spoonful every two hours of the following mixture : Morph. sulphas, gr. i ; 
spt. aramon. aromat, i^i; sulph. agth. comp. f5ij; liq- ammo, acet, f^ij ; aq. 
camph. f^i. This composed him, so that he was enabled to sleep, which he 
had not done for several days. 

March 7. He was quite delirious, requiring to be watched incessantly by 
his family. By using the mixture, he was quieted during part of the night : 
but, at 4 o'clock on the morning of March 8th, he escaped from home, and 
in the darkness having eluded his pursuing relatives, wandered out in a wood 
near to Girard College. There he picked up a piece of a porter bottle, with 
which he made a deep cut in the bend of his left arm, and also hacked off 
his penis and testicles, with the scrotum, at the pubis. 

When discovered, he was sitting on the ground bleeding very profusely, 
and actually gnawing at his lacerated and bloody organs. He was brought 
home at half past 8 o'clock A. M., when I saw him ; and, there being no 
hemorrhage from either of his wounds, whilst his powers of life were failing 
very fast, a glass of brandy was given to him, and he was sent to the Pennsyl- 
vania Hospital. Being an injury which resulted from mania dpotu, he was not 
admitted, but sent from thence to the Almshouse Hospital, where he came 
under the care of Drs. Stille and Gilbert, assistant surgeons of the institution. 
One of the spermatic cords was tied, but the other, having retracted into the 
abdomen, could not be found ; a T bandage was applied, and a catheter intro- 
duced through the remaining part of the urethra. Reaction occurred in the 
afternoon, but there was no return of hemorrhage. 

March \bth. On visiting the hospital to-day, I found the patient quite 
rational; he conversed very freely on his condition. Having slept eight 
hours during the previous night, felt better than he had since he entered the 
institution. The wound has a healthy appearance, but he complains of a 
stinging pain in the urethra; passes his urine in a full stream. Dr. Stille 
informed me that, during the past week, in consequence of being visited too 
frequently by his relatives, he had had attacks of delirium, and required occa- 

1 A case very similar to the one just recorded is related in Prof. Carpenter's Text- 
Book of Human Physiology. 



86 Taylor, Castration; Recovery, folloiced hy Phthisis Pulmonalis. [July 

sional doses of morphia, with watchers constantly at his bedside, to prevent 
his committing suicide or some violence on himself. The late Dr. Stewart 
(then house surgeon) informed me that the patient gave him the following 
account of his strange act : — 

Imagining that his relatives were accomplices of a crowd of demons who 
were constantly pursuing him, he succeeded in escaping from them in the 
darkness of the night, and ran towards Grirard College, intending to hide in a 
small wood near by. But, on approaching the place, he was met by a greater 
number of fiends, who, having caught and secured him, told him that, to ap- 
pease their anger and obtain his liberty, he must sacrifice his virility. Accord- 
ingly, he picked up a piece of a porter bottle which was lying on the ground 
near by, and performed the operation as before mentioned. Having so rude 
an instrument, he was three-quarters of an hour in excising the parts, whilst 
the lacerated manner of operating prevented much hemorrhage. 

April 20th. Through the care and attention of his physicians and nurses, 
he was enabled to leave the hospital to-day, and return to his home. The 
wound at the pubis had nearly healed, with the exception of a few unhealthy 
granulations, which were kept down by the use of nitrate of silver and a wash 
composed of the sulphate of copper and quinia. 

July 21st. I was requested to visit C. H., who, from exposure yesterday, 
had taken a heavy chill, and was then sufi"ering with a high fever, and a 
spasmodic stricture of the urethra ; this, however, was only partial, for the 
urine flows in a very small stream from a meatus urinarius, so contracted and 
hidden by the cicatrix on the pubis that it could scarcely be seen. With 
some difficulty, I introduced a probe, of the size of a knitting-needle, through 
the orifice ; to allay fever and dilate the passage, I fomented the pubes with 
warm water, and gave an infusion of senna and salts, with occasional doses of 
neutral mixture. These greatly relieved him ; so that, on the following day, 
I left with him a small Grerman-silver bougie, to use daily in dilating the 
orifice as I had previously done. Finding the use of this bougie to produce 
some spasmodic contraction of the urethra, it was changed for a silver one, 
which caused no uneasiness. By its use, and one or two of larger size, the 
passage became dilated to its usual dimensions. 

January^ 1854. Met C. H. ; he is very much improved in his appearance, 
being quite robust. His beard and whiskers are very thick. His voice is 
still masculine, but there is a slight hesitation or faltering in his speech, which 
I did not observe before the accident. This hale and hearty condition of his 
physical frame did not last long ] for, during the month of August, he began 
to lose flesh, and was aff"ected with night-sweats, together with great prostration, 
for which he took tonics. Obtaining no relief, and being also afi'ected with a 
troublesome cough, he applied to me on the fourth of November last. He was 
pale and greatly emaciated, had a hectic fever, a quick and feeble pulse, a dry 
cough, night-sweats, loss of appetite, with a general debility. Q-ave him a table- 
spoonful of the cod-liver oil three times a day, with an anodyne expectorant for 
his cough; but, being unable to give him any encouragement or hopes of a cure, 
he left me, nor did I see him again, but ascertained from some of his family 
that an "Indian Doctor" had undertaken to cure him. This empiric, however, 
could not keep away the great destroyer; for, in the latter part of December, 
1854, he fell a victim to phthisis pulmonalis. Can the loss of his virility have 
had any connection with the development of tubercular disease ? 

PniLAD., April, 1855. 



1855.] 



87 



REVIEWS. 

Art. XIIT. — The Pathology and Treatment of Stricture of the Urethra, both 
in the male and female; being the Treatise for which the Jachsonian Prize 
for the year 1852 was awarded by the College of Surgeons of England. 
By Henry Thompson, F. R. C. S., M. B. Lond., &c. &c. London : 
John Churchill, 1854. 8vo. pp. 424. 

It is not often that a prize essay succeeds so well as has this excellent mono- 
graph, in sustaining, among all classes of professional inquirers, the award of 
its official sponsors. The reputation of Mr. Thompson's work, as in most 
respects the best treatise on the subject in the English language, is already 
too well established to require further commendation at this time in any 
quarter. Our purpose, therefore, is not to eulogize it but to endeavour, in 
a cursory sketch of some of its most interesting features, to afford our readers 
a tolerable notion of the advantage to be gained by a closer study of its 
pages. 

To give an idea, at the outset, of the comprehensive and thorough manner 
in which our author has acquitted himself of his arduous task, we may here 
refer to the plan of arrangement adopted by him and described in the 
preface. 

The possession of manual dexterity and a practical familiarity with the 
best mechanical appliances are, he justly tells us, not the only essential requi- 
sites in the successful treatment of stricture. An intimate acquaintance with 
the pathology of the entire genito-urinary system, with its sympathetic and 
functional relations in health and disease in all directions, is no less indis- 
pensable. He does not pretend to consider in extenso, within the compass of 
a single volume, the various topics suggested by the broad view thus taken 
of the question. Voluminous and rich in valuable matter, as his production 
obviously is, he would seem to regard it as presenting only a brief review of 
the most important considerations involved in the study of the subject. Be 
this as it may, our own impression is that few students and practitioners, 
however great their reading and practical experience, could rise from a careful 
examination of his clear, ample, and impartial expositions, without having 
acquired a material addition to their previous stock of knowledge in relation 
to the entire subject of inquiry. 

In the first place : Mr. Thompson has freely and carefully collected from 
standard authorities in regard to all important points, quoting the writers^ 
words in each case, and making the direct reference to page and edition of 
each particular citation. 

Secondly : Original researches have been made whenever practicable, and 
their results compared with those of previous similar investigations by other 
hands. 

"Thus the Chapter on the Pathological Anatomy of Stricture is mainly a 
digest of the facts now exhibited in the principal museums belonging to the 
medical schools of London, Edinburgh, and Paris, in which each preparation 
has been individually examined by himself. A reference is made in the text 



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to various specimens of importance, and an account of these is placed in the 
appendix, for the purpose of facilitating the student's acquaintance with un- 
questionable examples and illustrations of the facts stated." (Pp. 8, 9.) 

Thirdly : Under the head of " reported cases/' a large number of hitherto 
unpublished observations are collected for the purpose of illustrating nume- 
rous points connected with the natural history and treatment of stricture. 
Following these is a " table of cases," 220 in number, " condensed from fully 
reported cases only, upon the aggregate of which have been founded, in a 
great measure, the chapters on ^ the symptoms/ and on the ' causes of stric- 
ture.' " (P. 9.) 

Then, in connection with the much mooted question of perineal section, 
certain data required for its discussion at full length are presented under 
the head of ' outlines of cases,' which are merely very short histories contain- 
ing the principal facts bearing on this question." (P. 9.) 

Lastly : — 

"No pains have been spared in order to develop the best practical mode of 
conveying, as far as this can be done on paper, sound information respecting 
the anatomical relations of the healthy and diseased urethra." '* It will be 
seen," continues he, " that a great number of bodies have been examined to 
supply the facts related. One, out of several illustrative preparations which 
were sent into the College of Surgeons with the Essay, contained portions of 
the corpus spongiosum from not less than twelve bodies, to illustrate a point 
in its anatomy referred to at pages 38-41." (P. 10.) 

On looking over the list of contents, we find them to be divided into twelve 
chapters, occupying three hundred and eighteen pages; and an appendix, 
already alluded to, of six valuable notes, which, with the index, take up the 
remaining hundred pages. These chapters are furnished with marginal 
headings ; a means of ready reference of so much utility, and so rare, unfor- 
tunately, in medical books, that we consider the author entitled to special 
thanks on their account alone. 

Chapter I., "On the Anatomy and Physiology of the Male Urethra," is 
one of the longest and best of the book. It yields to none of them in interest 
and character, and would stamp its author as a profound investigator, even 
were it the only original portion of his treatise. The descriptions of previous 
anatomists are diligently and faithfully compared with the results of his own 
"repeated dissections and researches into certain conditions of the organ, 
which are illustrated in the tables and drawings accompanying this volume." 

Comparing his measurements of the male urethra after death with those 
of Mr. Briggs during life, he calls attention to the difi"erence in length under 
the different conditions of life and death. 

" It will, therefore, be borne in mind that these two measurements of 7f 
inches, and 8| inches, respectively, relate to the average length of the urethra 
in the two conditions of life and death. That this difference exists, it will be 
particularly important to recollect since all accurate researches into the patho- 
logical anatomy of stricture are, of necessity, confined to an observation of the 
parts after death; while in relation to treatment, the measurement during life 
is that which alone must be remembered." (P. 4.) 

In relation to width, or capacity for extension of the urethra, we have room 
only for the concluding remark. 

"As regards the actual average of measurements met with in practice, it is 
seldom that No. 12 cannot be fairly introduced into the adult urethra, while 
Nos. 13 and 15 are often admissible. The diameters of these instruments are, 
respectively, three-tenths and three-and-a-half tenths of an inch," (P. 8.) 



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Passing over the anatomical divisions of the urethra^ its mucous membrane, 
the perineal fasciae, and the characters and relations of these parts respect- 
ively, we are arrested by a most interesting account of the muscular tissues, 
and especially of the " involuntary muscular fibre,'' which the researches of 
Hancock and Kolliker have already introduced to general notice. The spe- 
culations of John Hunter, Home, Wilson, and their adversaries for and 
against the probable existence of these fibres, are successively reviewed ; and 
the microscopical demonstrations, first of Kolliker and then of Hancock, are 
given at full length in their own language. The views and reclamations of 
the latter author are well known to English readers through his admirable 
*'Lettsomian Lecture,^' and subsequent tract ''On the Anat. and Phys. of the 
Male Urethra, and on the Path, of Strictures of that Canal," published in 1852. 
Mr. Thompson endorses the authority of the Cyclopedia of Anatomy and 
Physiology in giving to the German microscopist the credit of " first pub- 
lishing the fact of the existence of involuntary muscular fibres, although the 
account he (Kolliker) gives is not in all respects corroborated by the re- 
searches of English anatomists." (P. 18.) 

Mr. Hancock, on the other hand, who concedes " the priority of noticing 
these fibres" (see Hancock, op. ciiat. p. 9), is supported by our prize 
essayist in claiming the honour " of describing their situation and arrange- 
ment, and their importance as bearing upon practical points." (P. 19.) 

Hancock's description, according to Mr. Thompson, " is more definite and 
comprehensive than Kolliker' s, and possesses additional value from the fact 
that it appears to have been rendered altogether independently of any other, 
and in unconsciousness of its existence. It moreover contains fresh informa- 
tion respecting the subject, while it is somewhat at variance with the state- 
ments of Kolliker, in one or two particulars." (P. 20.) 

In corroborating the demonstrations of his confrere, our author gives the 
following directions as to the best mode of dissecting for the purpose : — 

" Lay open a urethra from the upper part; stretch out a portion by means of 
pins upon a board, and dissect up carefully a small flap of mucous membrane 
from any part of the canal, that of the prostate or of the glans penis being 
the parts from which they can be most easily demonstrated; and the elastic 
and non-elastic fibres, before seen lying beneath the transparent membrane, are 
exposed ; these being removed by degrees, a grayish layer comes into view, a 
small portion of which, placed under an object-glass of a quarter of an inch 
focus, with a small quantity of water, will exhibit the appearances peculiar to 
the unstriped fibre, which it is unnecessary to detail here.^' 

He remarks, in continuation, that " it is, however, a subject well deserving 
further investigation, as it requires to be explained how it is that the adult 
urethra, in which we might naturally expect them to be most fully developed, 
affords them less readily than that of the foetus.'" (P. 23.) 

Next in order come a very instructive, and in some respects original, series 
of reflections on the anatomy and physiology of the voluntary muscles of the 
urethral canal ; on the structure and relations of the corpus spongiosum, espe- 
cially of its bulbous portion and the fibrous covering and partition of the 
latter, together with the distribution of its arterial branches, in relation to 
hemorrhage ; on the direction of the canal, and its relations with the fascia; lastly, 
on the urethral curve, with its variations in youth, adult age, and in individu- 
als of spare, corpulent, or other conformation. The discussion of the urethral 
course and curve, and the practical inferences derived therefrom, are illus- 
trated with the best diagram and dissection that we have ever found in Europe 
or America, although we have long been in the habit of looking for such a 
preparation at every opportunity within our reach. There is so much practi- 



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cal information given in tbis latter division of tlie chapter, that we would 
gladly transfer a considerable portion of it to our pages. Justice to the re- 
maining topics of the work, however, obliges us to restrict ourselves to the 
resumi, with which it terminates. 

" 1. That the urethra is composed of a delicate and sensitive mucous mem- 
brane, exceedingly vascular and well supplied with nerves, the area of which 
is increased by numerous small glands and follicles ; and that it is closely con- 
nected by its submucous areolar tissue with involuntary muscular fibre in every 
part of its course, the distribution of which is not quite equal in quantity 
throughout. 

''2. That in some parts lying between the two, in others, often interlacing 
with these contractile fibres, but for the most part lying in longitudinal bun- 
dles beneath the mucous membrane, and united by transverse fibres, is also a 
varying amount of the yellow elastic tissue. 

" 3. That in the prostatic and in the spongy portions of the urethra, the 
glandular and erectile structures respectively, lie next in order to the above- 
mentioned contractile tissues (proceeding from within outwards), are both 
largely composed of involuntary muscular fibres, and enveloped by an outer 
layer of the same, which, while they act by evacuating, in either case, the con- 
tents of the organ — in the one, a glandular secretion ; in the other, the blood 
supplied for erection — form also an agency which, in certain states, is brought 
to act more or less on the capacity of the urethral canal, and this agency may 
be somewhat increased by the co-operative action of the accelerator urinse 
muscle. 

"4. That in the membranous portion there is also close contact of voluntary 
muscle, the disposition of the fibres of which is such that it cannot be doubted 
that, whatever may be its degree or extent, its function is to close the canal at 
this point ; the sphincteric character of the muscle being most strongly indicated 
by its structure, as well as by what we infer respecting its actions, as mani- 
fested by phenomena both natural and morbid. 

"5. That not only does vascular or erectile tissue surround the whole of the 
spongy part of the urethra, but that a thin layer of it encircles the membran- 
ous portion also, and that from the peculiar structure and function of this 
tissue, laceration or division of it may be attended with considerable loss of 
blood. 

*' 6. That while the prostatic part is movable to a small extent in a direc- 
tion upwards and downwards in obedience to muscular action, the menbranous 
is nearly fixed and constant in position, from the application of unyielding 
structures (fasciae) to it, in such a manner as greatly to limit the mobility of 
the part ; and lastly, that, within certain limits, the spongy part is movable in 
any direction, the bulbous portion being less so in the ratio of its proximity to 
the anterior layer of the deep perineal fascia by which it is partially retained 
in situ, as well as by the corpora cavernosa, and by the triangular ligament 
above, uniting the penis to the pubes ; the anterior two-thirds of the passage 
(more or less in difi'erent subjects} being, for the most part, perfectly free from 
mobile." (Pp. 47-48.) 

" Classification and Pathology of Strictures of the Urethra," are the sub- 
jects of the second chapter. Under this head "we have, in the course of forty 
pages, abundant evidence of the characteristically laborious, as well as prac- 
tical and discriminating manner in which our author masters the various 
questions which have puzzled his predecessors in the same field of investiga- 
tion. His unwearied examinations and analyses of the vast number of cases 
and preparations continually referred to throughout his book, have given him 
a vantage ground, which places him beyond the reach of most competitors, 
while they must save a world of trouble to all who may hereafter follow him 
in similar pursuits. 

He adopts the classification of strictures into permanent and transitory, 
the former only being organic and the latter being inflammatory or spasmodic. 



1855.] 



Thompson, Stricture of the Urethra. 



91 



In studying the morbid anatomy of permanent organic stricture, be has de- 
duced it, in a great measure, " from a close personal examination of more than 
three hundred preparations of stricture in the museums of tbis country [Great 
Britain] and of Paris, and of a number, almost equal, of preparations of the 
bladder, kidney, &c., which illustrate concomitant morbid conditions ; as well 
as from the observation of recent specimens in the dead-house, which has been 
enjoyed by the author to a considerable extent." 

We have room to note a very few of his conclusions. He believes that 
obliteration of the urethra by actual adhesion of its walls " probably never'' 
does occur, unless as a consequence of fistulse, " when, although very rarely, 
this accident may happen.'' " Nevertheless," continues he, " obliteration of 
the urethral canal does occur, but it is almost invariably of traumatic origin." 
He has '^once, and once only, met with an impermeable stricture in the dead- 
house, and failed in attempting to pass a bristle or an eye-probe through it, 
after the urethra had been slit up to the point of contraction ; urinary fistulas 
were present." (P. 64.) 

With regard to the locality of stricture, his observations lead him to coin- 
cide unhesitatingly with the prevalent opinion which places the most fre- 
quent seat of the contraction '^at the posterior limit of the spongy portion." 
In designating the different points of coarctation, he considers that the only 
accurate method is to identify them with the anatomical regions of the urethra, 
since all measurements from the orifice merely must be wanting in precision. 
In accordance with this view, and desirous also of simplifying the arrange- 
ment as much as possible, he has comprehended all examples of the disease 
in three classes: — 

** I. Strictures occurring at the subpubic curvature, i. e., at the junction be- 
tween the spongy and membranous portions and its neighbourhood ; the latter 
term being understood to comprise an inch of the canal before, and three- 
quarters of an inch behind that point, thus including the whole of the mem- 
branous portion. 

" The junction itself is the point at which stricture is most frequently situ- 
ated. Next is the extreme anterior boundary of the division, a spot which is 
one inch in front of the preceding, and almost as frequently affected ; while, 
between these two points, six examples of stricture are met with for every 
one behind the junction, in which latter situation, therefore, they are very un- 
common. Most rarely is a stricture found so far back as the posterior part of 
the membranous portion. 

" II. Strictures occupying the centre of the spongy portion, i. e., a region extend- 
ing from the anterior limit of the preceding, to within two inches and a half 
of the external meatus, and measuring, therefore, about two and a half to three 
inches in length. 

"III. Strictures occurring at the external orifce and within a distance of two 
inches and a half of it." 

The following analysis of two hundred and seventy preparations referred to 
is then given ; these preparations exhibit three hundred and twenty distinct 
strictures, viz : — 

In region I. 215, or 67 per cent, of the entire number; in region II. 51, or 
16 per cent. ; in region III. 54, or 17 per cent. = 320. Of these there were — 
185 examples of 07ie stricture only, situated in region I. 
17 " " " II. 

24 " " III. 

There were 8 cases in which the urethra was strictured in all three regions. 
" 10 " *' *' '* in region I. and II. only. 

10 " " " - " 1. and III. only. 

13 " " " II. and III. only. 



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Lastly, he confidently asserts " that there is not a single case of stricture 
in the prostatic portion of the urethra to be found in any one of the public 
museums of London, Edinburgh, or Paris." He is " disposed to believe that 
some observers have been deceived in reference to it, or that it owes its sup- 
posed existence to inferences drawn from the results of examinations of the 
living body, which can by no means be admitted as evidence on this subject. 
* * * * At present, therefore, the existence of prostatic stric- 
ture appears to rest on the observations of Leroy d'Etiolles and Ricord." We 
are under the impression that a case is reported also by Lallemand. At all 
events, as Mr. Thompson justly says, its excessive rarity at least is demon- 
strated. 

Chapter III., which, like all the others, presents some very useful practical 
lessons, is occupied with the " Symptoms and Pathological Effects of Organic 
Stricture.*' The general and local consequences of long-continued or aggra- 
vated and even of slight affections of this kind, the fatal effects of slight in- 
juries to the urethra in some cases, the dangers of rapid or extreme dilatation, 
the frequency of anomalous neuralgic pains dependent on the presence of 
stricture — are all judiciously impressed upon the reader's attention. 

Chapter IV. presents us with a valuable discussion of the " Causes of Organic 
and Permanent Stricture." After quoting the leading authorities in relation 
to this topic, Mr. Thompson then turns to his tabulated cases. Of these, he 
has collected and arranged for the purpose from various reliable sources, two 
hundred and twenty, which are presented in the Appendix, Note F. We 
quote the analysis of these cases with which the chapter concludes : — 

" Antecedents or supposed causes of organic and permanent stricture and 
gonorrhoea! inflammation, in 164; injury to perineum, in 28; cicatrization of 
chancres, 3 ; ditto after phagedsena, 1 ; congenital, including cases in which 
the urethra may have been small from malformation, and those in which 
marked irritability of the organs existed from chilhood, accompanied by an. 
unusually small stream, 6 ; poisoning by nitrate of potash, lithotrity, masturba- 
tion, of each, 1 (Lallemand) ; met with among the ordinary published cases in 
the journals, 3 ; true inflammatory stricture, including temporary stricture and 
retention from a sudden acute inflammation, usually caused by some excess, 
and disappearing by resolution, 8 ; true spasmodic stricture caused by irrita- 
tion about the rectum, 2; ditto without assignable cause, 2; ditto caused by 
undue acidity and alkalinity of urine, 3. Total, 220. 

"Respecting the first class of cases, the following facts are elicited : Of the 
164 cases attributable to gonorrhoea, in 90 the disease is reported to have been 
chronic or neglected ; in 3, it was attributed by the patients to strong injec- 
tions ; in 6, the discharge is stated to have ceased entirely and rapidly under 
treatment ; but in 5 of them, stricture appeared almost immediately after ; in 
4 other cases the stricture appeared to be almost simultaneous with the gonor- 
rhoea ; in the remaining 61, there is no report of chronicity, &c. Of the 164 
cases attributable to gonorrhoea, 10 appeared immediately after or during the 
attack ; 71 appeared within 1 year of its occurrence ; 41 within 3 or 4 years; 
22 within 7 or 8 years ; 20 are reported at periods between 8 and 20 to 25 years.'^ 
(Pp. 132, 133.) 

Next in order comes Chapter V., ^^On the Pathology of Strictures of Tran- 
sient Duration." This treats of a class of disorders which are continually 
urging themselves, and often most unpleasantly, on the attention of the general 
practitioner as well as the professed surgeon, since they more frequently pre- 
vail among the wealthier portions of the community. The hints it conveys 
are therefore especially important to every medical inquirer. We have 
marked several, but must leave them to be found in the book itself, while we 
hasten on to the " Diagnosis and Treatment of Stricture of the Urethra/' 



1855.] 



Thompson, Stricture of the Urethra. 



93 



which occupy our author in his remaining chapters, with the exception of the 
tenth, eleventh, and twelfth. 

Here we are at once introduced to the endless armamentarium of sounds, 
bougies, and catheters, in all their conflicting varieties. Hard, soft, and flexi- 
ble—long curves, short curves, and angular — straight instruments and twisted 
— blunt ends, olivary, fusiform, and conoidal — stylets, lancets, and porte 
caustiques, one after the other, pass before us in a motley crowd to usher in 
the no less varied arts and mysteries of cast taking, measuring, the tour de 
maitre^ preliminary sounding, vital dilatation, gradual dilatation, permanent 
dilatation, immediate or forced dilatation, cauterizing, internal incision, and 
external incision. These, and other perplexities and terrors of present and 
former days, are marshalled in their wonted shapes of wax, gum, tin, lead, 
steel, German silver, and genuine silver ; but they are not, as of old, allowed 
to overwhelm the bewildered student and practitioner. Each implement and 
process, that deserves it, is fairly and rationally considered; and m.any of both 
are put aside, we trust, forever. 

The diagnosis of stricture can, of course, only be determined by physical 
exploration, which must be efiected by the passage of an instrument along the 
suspected canal. For this purpose our author prefers, as most reliable and 
most easily directed, a solid silver sound, or, which is much cheaper and 
almost equally useful, a well-polished steel one, silver plated, the chief advan- 
tage of the former material being that it permits slight alteration to be made 
in its form for special cases, witbout sustaining injury.'^ The reasons given 
for this preference are the usual ones, and need not be repeated here. Our 
own experience has long since led us to the same conclusion in ordinary 
practice. 

With regard to the curve of a sound or catheter, he remarks, that it should 
naturally be adapted to that of the least movable portion of the urethra itself, 
which he has previousl}^ shown to be ^' equal to a portion of the circumferen- 
tial line, equal to about three-tenths of a circle three inches and a quarter in 
diameter.'^ The instrument, in its transit to the bladder through a healthy 
organ, " must describe a curve, and turn round an axis which may be imagined 
to exist about the centre of the symphysis pubis and, necessarily, will most 
readily do this if its own curve corresponds with that described (p. 158). 
This principle is very clearly illustrated by a diagram representing a catheter 
and bougie of the size and curve proposed. He further informs us that he 
had adopted and advocated such a curve on the ground of practice after long 
trial of difi'erent forms, and before having arrived at any theoretical conclu- 
sions on the subject. We are glad to find an old and well-tried predilection 
of our own for a very similar bend confirmed by such authority. Although 
it is well known, as he reminds us, that difi"erent curves have been equal 
favourites and equally successful in many eminent hands; and that under the 
direction of an able operator almost any form may seem the best, still the 
direction which would be most likely to facilitate the manoeuvres of unprac- 
tised manipulators is undoubtedly of serious importance. We, therefore, 
second his advice respecting catheters and sounds as, throughout, worth the 
especial attention of the great majority of general practitioners, and, above all, 
of the beginners in this exercise. A very few. trials on the dead or living 
body, and especially upon themselves, would probably assure them of the 
value of the precepts which Mr. Thompson has explained and applied with 
mathematical clearness and precision, while he appeals to a prolonged and 
abundant experience for their practical demonstration. In speaking of the 
eyes of catheters, he objects to the usual size^ and advises that smaller openings 
No. LIX.— July 1855. 7 



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should be made, on account of the protruding of the mucous membrane into 
them when too large. We have often been struck with the increased pain 
and difficulty arising from the suction of the mucous lining through the aper- 
tures of the ordinary catheter during the exit as well as entrance of the instru- 
ment, especially when quickly done. We have no doubt that it is a frequent 
though rarely appreciated source of trouble to the patient, if not to the sur- 
geon ; and hence have for years past preferred using an instrument perforated 
around its extremity, like the female catheter, with numerous small holes 
instead of the larger elliptical fenestra on the sides. The objection to these 
cribriform terminations, that they are apt to become clogged, is not found to 
be very great in practice, and is easily obviated by slightly enlarging the holes 
so as still to secure the object which our author seeks in reducing the dimen- 
sions of the lateral clefts. 

Mr. Thompson's whole account of the mode of introducing the catheter may 
be as warmly recommended to our junior readers as that of the instrument 
itself. It is admirably clear, judicious, and complete. " The more quietly, 
gently, and unostentatiously these manipulations are accomplished, the more 
credit will the operator obtain for the possession of a light and easy hand.'^ 

We shall never forget the lesson long ago afforded us, and after a good deal 
of hospital practice and observation elsewhere, by the example of Civiale, in 
the slowness, steadiness, and perfect gentleness with which that unsurpassed, 
if equalled, catheterizer invariably operated on his patients. " Whatever the 
obstruction, it is never to be carried by storm. A patient, persevering, and 
unruffled spirit, with a dexterous hand, will work miracles in cases of difficult 
catheterism" (p. 167). How many a poor fellow, in his hour of agony, has 
felt the force, either for good or evil according to his trial, of the caveat thus 
announced? 

A protest has been entered against the suggestion of Mr. Thompson, that 
the surgeon who wishes to excel in this kind of performance should try it on 
himself. The idea is not a new one. It is an old and favourite expedient 
with some practitioners who certainly did not think of martyrizing themselves, 
although they wished to save their patients. Ad hominem though it be, we 
willingly subscribe to this mode of training, and none the less so because we 
have some knowledge of its convincing properties from personal experiment. 
The only other mode of arriving at an equally positive idea of the action of 
different forms, sizes, and kinds of instruments upon a healthy urethra is to 
make one's self the experimentum crucis, under the tender mercies of a second 
party ; a stretch of devotion to the cause of good catheterism which we freely 
confess to be even beyond our ambition. Cautious self-catheterizing, however 
disagreeable, ought not to be lost sight of by the enterprising student, as the 
very best means of acquiring a practical understanding of the art in general. 

The operator who is unable to withstand such a trial of his strength of 
nerve can hardly be qualified to perform the office for another. Indeed, we 
hold that no man of an irritable temperament, or little self-control, should 
ever undertake the introduction of a catheter in any case, much less the treat- 
ment of a stricture. ^'Festina Lente must be a motto never for an instant to 
be forgotten ; one moment's loss of self-command, and irreparable mischief 
may be done.'' (P. 180.) 

The innumerable plans of treatment are resolved into three classes : Those 
which produce dilatation through pressure, mechanically and by absorption ; 
those which effect a similar result through the chemical or absorbent action of 
caustics ; and those in which the opposing tissue is divided from within or 
from without, by some cutting instrument, each process being, of course, 



1855.] 



Thompson, Stricture of the UretJira. 



95 



accompanied by the use of constitutional remedies. The employment of dila- 
tation is placed first in order, as not only the oldest, but by far the most de- 
sirable and most generally applicable method of treatment. It is the one 
which is resorted to in the vast majority of instances as the rule, and only 
laid aside for other modes when proved ineffective or insufficient to maintain 
a cure. 

The author's views as to the proper mode of ordinary instrumental and 
general therapeutic management, are very well shown in the statement of two 
hypothetical cases, the one simple and the other more difficult. In reviewing 
these and other illustrations we have not time to follow him in detail, and 
must content ourselves with an occasional note. He uses a metallic sound or 
catheter whenever the size of the opening through the stricture will admit of 
it, advises an attempt at gradual dilatation in all cases, and strongly depre- 
cates the exercise of violence or haste. In certain difficult forms of stricture, 
he is satisfied that where no false passages exist, and when they can be avoided, 
"the employment of continued pressure on the face or in the commencement 
of a stricture is almost uniformly successful." The operator must take care, 
however, that he is really acting on the contraction alone. He must remember 
as an invariable test of genuine progress, that when the instrument is tightly 
grasped he "may infer that its point is safe within the strictured part, but that 
when the point feels free, movable, and capable of being withdrawn without 
appreciable effort, it is certainly not in the stricture; it may be, in such cir- 
cumstances, in a false passage." 

In the management of a narrow stricture, he advocates, with good reason, 
we think, the employment of conical sounds, and proposes three different 
sizes, made of solid metal and well polished, as an efficient set. Silver-plated 
steel sounds of this form have long been very widely used in Philadelphia, 
and, so far as we have learned, with general satisfaction. 

Respecting the use of force, which may be allowed in particular excep- 
tional cases, the following conditions are stated as indispensable : — 

1st. When required, " it may only be made after the point of the instrument 
has well and fully entered the stricture, so that the operator is assured that it is 
in the right track. Force is never to be employed in order to make a vjay into 
it." 

2d. " It is then to be increased very gradually, first trying one uniform rate 
of forcible pressure for two or three minutes before proceeding to increase it ; 
and, when it is found necessary to do so, the increase must be continued in the 
same manner for a similar length of time. It is not to be accomplished by 
pressing onwards with more and more violence, until something gives way. 
This is never legitimate." 

3d. " Complete knowledge of the anatomy of the passage, some acquaintance 
with its diseased conditions also, and long experience in the use of instru- 
ments in it, are the indispensable qualifications of the operator to whom the 
use of force is permitted." (P. 183.) 

Not satisfied with these express rules, he follows them up with a warning as 
to when force should not be used, so anxious is he to be clearly understood. 

In dealing with those most troublesome accidents, false passages, we find 
two valuable hints, which, although not new, deserve renewed attention. 

1st. " That they almost invariably commence on a level below that of the pro- 
per opening ; and, secondly, that the operator's finger when in the rectum, 
near to which the false passage is almost certain to run, will communicate in- 
formation as to the route which the catheter is taking, whether it be too close 
to the gut, or deviating to the right or left of the median line ; it will, more- 
over, be serviceable in assisting him to guide the point in the true direction." 
(P. 187.) 



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The remainder of Chapter VI. is occupied with the careful consideration 
of many topics of practical interest; such, for instance, as the relative merits 
and respective uses of flexible and inflexible bougies ] Dupuytren's method 
of retaining a catheter for hours or days against Si stricture, called " vital 
dilatation the method of retaining a catheter within a stricture, or " me- 
chanical dilatation f the injurious effects of rapid or extreme dilatation, &c. 
&c. The closing paragraphs of this chapter relate to the unfortunate fact 
that there are cases in which dilatation is only temporary in its action, and 
which are therefore incurable by this method. The question is consequently 
asked. In what manner can such cases be relieved ? The answer to this fol- 
lows in the two succeeding chapters, VII. and VIII., which contain a full 
and very fair discussion of the use of " chemical agents" in the shape of 
caustics, and of the resort to cutting instruments internally and externally. 

His personal acquaintance with the caustic treatment does not appear to be 
extensive, and his impressions are certainly unfavourable. Still, he gives us 
a candid and sufficiently comprehensive history of the escharotic method in 
the hands of its most prominent British and French advocates, from Wiseman 
and Pare down to Leroy d'Etiolles and Wade of our own day. 

Nitrate of silver and caustic potash are the only caustics used, the former 
being preferred exclusively by most authorities. All modes of application 
may be resolved into two categories. "Either a small instrument containing 
it is introduced into the stricture, which cannot then be a narrow one ; or a 
small portion of the agent is carried down to it and pressed against its ante- 
rior surface." His conclusions are expressed in the following extract : — 

" That these agents are never to be employed for the sake of their escharotic 
or caustic povrers, properly speaking.^' 

" That the nitrate of silver, lightly applied, exerts a salutary action on the 
diseased surface of the urethra, relieving inordinate irritability, and checking 
undue vascularity and disposition to hemorrhage, as it does in similar condi- 
tions of the skin and mucous membrane in other parts of the body, and thus it 
becomes a useful adjunct to dilatation.^^ 

" That the potassa fusa, as a caustic, is considerably more active than the 
preceding, and is therefore more dangerous of application. If used at all, it 
should be only in very minute quantities, such as fractional parts of a grain, 
inasmuch as it is exceedingly difficult to limit the action of so powerful an 
escharotic. It may perhaps aid dilatation in the reduction of some strictures, 
probably by facilitating the solution of some of their component tissues, when 
care is taken to employ it in obedience to the condition just named.^' (P. 221.) 

We are inclined to consider this appreciation just enough, as far as it goes, 
but would have been glad to see it carried on a little further. Under the 
direction of a tyro or incompetent operator, the employment of any escharotic 
in the urethra might be very dangerous; but, in skilful and experienced 
hands, we know it to be not only safe in many instances, but highly service- 
able. We have heard of cases in which frightful mischief has been produced 
by the improper use of caustic potash; but from what we have repeatedly 
observed of its careful application as a powerful stimulant to absorbent action 
on other surfaces, we have no doubt that, when properly diluted and other- 
wise modified or guarded in its action, and o]jportunely employed, it may 
prove a most valuable aid to milder means. So, also, with nitrate of silver, 
with the action of which, combined and uncombined with milder salts, we 
have long been more familiar in the management of stricture. So much de- 
pends upon the strength, the mode and the time of application, that the 
philosophy of this species of treatment would seem to consist, as it does even 
with the bougie, rather in attention to the minor details of its application than 



1855.] 



Thompson^ Stricture of the Urethra. 



97 



in the mere indefinite resort to one or the other of two powerful agents in 
their primitive shape. The objections and caveats are levelled against their 
abuses only, while their true applications and legitimate availability are scarcely 
estimated in the manner which the fulness and precision of the previous 
chapters had led us to expect. 

We come next to the treatment by intra-urethral incisioUj which is the 
subject of Chapter YIII. Passing over the excellent history and principles 
of this plan of treatment, together with the author's brief but comprehensive 
descriptions of the various instruments and modes of operating, we shall pro- 
ceed to quote his summary of indications. 

" 1st. When dilatation has been sufiaciently tried, and does not afford relief, 
or that which is temporary only in its duration (and the stricture is not of an 
irritable character, in which case, as we have seen, a trial of the caustic may 
first be made) 

" 2d. And the stricture is known to consist of a mere fold of membrane, or, 
at all events, is a short one, i. e. of small extent from before backwards 

" 3d. When this is situated in the anterior three or four inches of the urethra, 
the case is one which most probably will be successfully treated by division, 
according to the modes already recommended, the choice of which should be 
determined by rules already given.'^ (P. 233.) 

The objection to all internal cutting instruments is that the operator has 
no means of ascertaining clearly how far or what he cuts. Instruments for 
the purpose ought to be constructed with a guide. 

Thus the attempt to perforate an obstruction otherwise impassable by 
pushing a pointed blade into it without a guide, must be always somewhat 
hazardous ; extremely so, if it be attempted in the curved part of the urethra. 
* ^ * Less dangerous is it, as we shall hereafter see, to lay open the peri- 
neum and divide the stricture from without, thus giving free vent to noxious 
fluids of all kinds, than to wound the urethra from within, at or behind the 
bulb, as we run great risk of doing when operating at six inches distance from 
the external meatus, and thus only make a channel for these matters into the 
erectile cavities and other structures round.'^ (Pp. 224, 225.) 

Chapter VII. concludes with a short summary of the general rules of treat- 
ment thus far established. 

" Dilatation has been found successful for the great majority of cases, but 
certainly inefficient for the cure of some old and extensive strictures, as well as 
for some which are accompanied by a highly irritable condition of the urethra, 

" Cauterization must be regarded as a useful adjunct to dilatation in some 
few cases, especially in some of those in which a considerable degree of irri- 
tability exists. It is wholly inapplicable to the removal of old and extensive 
contractions. 

'■^ InUrnal division is particularly suited to these last-named cases, when 
situated in the anterior part of the urethra. 

" There remain, therefore, by process of exclusion, some very irritdhle stric- 
tures, and some ohstinate and extensive ones ; the latter being usually situated 
about the junction of the spongy and the membranous portions, or a little an- 
terior thereto, for which at present no adequate remedy has been described." 
(Pp. 234, 235.) 

These are the bad cases on account of which, in addition to those of reten- 
tion and of urinary fistula, the more extended application of external urethro- 
tomy has, of late years, been especially discussed. It is well known that the 
operation of perineal section, with or without a guide, but particularly in 
-impassable stricture — the buttonhole incision, or houtonniere, as the French 
call it — is a very old one, familiar in some shape or other as one of last resort 
for at least two centuries. 



98 



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[July 



The earliest record whicli Mr. Thompson gives us of such an operation 
performed for the cure of stricture, and not for the relief of retention,' is 
that of an unsuccessful one related by Wiseman {Chirurgical Treatises, 5th 
ed. vol. ii. p. 427) as having been attempted in 1652. We find in Saviard's 
Surgical Observations (London Translation, by J. S., p. 167); a report of 
an equally unfortunate attempt made by himself in 1692. 

Other and later French and British Surgeons appear to have tried it for the 
same purposes from time to time, with various success; and in America, it was 
advocated in 1824 by Dr. H. Gr. Jameson^ who had practised the incision in the 
median line for the cure of obstinate stricture as well as for the relief of 
retention, first in 1820 and repeatedly thereafter, with results so gratifying 
as to induce him to recommend the operation as not only very efficient but 
entirely safe. [Medical Recorder, vol. vii. p. 283, and p. 713.) Mr. Thomp- 
son shows that the practice of the operation, both through the raphe and by 
its side, in cases of retention, appears to have been adopted by British sur- 
geons early in the present century. It has certainly been frequently re- 
sorted to in the United States as well as in the British Islands and on the 
European Continent, throughout the last thirty or forty years, in the 
management of perineal fistula and as a favourite means of rescuing the 
victim of retention from the dangers of this accident. The operation has 
long been a familiar one in Philadelphia (see for instance Horner's lateral 
section, in H. H. Smith's Operative Surgery')] and the recent interesting 
paper of Dr. Lente (quoted in the last No. of this J ournal, from the New 
York Journ. of 31ed. for March, 1855) proves that it has been equally com- 
mon in New York. Fergusson tells us, in his Operative Surgery (4th Am. 
ed. p. 583), that he has been accustomed to see and treat cases of the kind 
with the usual cutting operation for the last five and twenty years. Bransby 
Cooper says much the same. Mayo and others also refer to it in a similar 
manner. Guthrie describes the section in the perineal raphe as first taught 
by him in 1816, and published in 1830. Mr. Simon alludes to Guthrie's 
operation as the one in established use among the hospitals of London for the 
last thirty years. We have, also, among the recent French descriptions of it, 
that of Yidal de Cassis, who is decidedly in its favour as less formidable than 
is generally supposed ; and that of Sedillot, which corresponds, in its method, 
with the procedure as modified by Avery and recommended by our author. 
All have regarded it as a very serious expedient, to be undertaken chiefly if 
not solely as a dernier ressort, although one that should not be deferred, as it 
too often is, until the patient is likely to sink under the efiects of the mis- 
chief produce^ by the injury itself. 

We must refer the reader for the detailed steps of the operation, as per- 
formed in cases of impermeable stricture, and for Mr. Thompson's apprecia- 
tion of its value and particular uses, to his own pages ; and shall proceed at 
once to the new application of perineal section as presented by Mr. Syme. 

Although the idea of performing external incision, with a guide in the 
urethra, and for the cure of stricture alone, is an old one, and occasionally 
put in practice as well as recommended on both sides of the Atlantic long 
before the professional advent of its Edinburgh advocate; still that able 
and indefatigable surgeon is entitled to all the credit due to its establishment 
as a standard operation. He deserves, too, the perhaps more substantial 
honour of having first definitely ascertained and announced the principles of 
this mode of treatment, and, in accordance with these, the proper method of 
procedure before and after, as well as during the performance of, the ope- 
ration. 



1855.] 



Thompson; Stricture of the Urethra. 



99 



Mr. Thompson appears to us to have succeeded in preparing not only " a 
fair and correct exposition of the much vexed c^uestion, but the best and most 
useful one yet published and in doing so has very materially enhanced the 
value of his monograph. It is, to use his own words, truly "a laborious, 
careful, and, as far as possible, an unprejudiced examination of the evidence pre- 
sented in relation to the subject and, as such, must particularly interest 
our readers now that a considerable interval has elapsed since the discussion 
first arose. We regret, therefore, that the already tedious length of this 
review will oblige us to curtail the summary of this portion of our author's 
essay. 

Putting retention of urine and urinary fistula out of view, and confining 
ourselves to the consideration of stricture solely, Mr. Thompson reminds us 
of the old axiom among surgeons, both in theory and practice, " that ichen a 
sound of any size can he passed through ci stricture into the bladder, division 
of the stricture from the surface of the perineum is certainly contrcL- indicated." 
Mr. Syme reverses the rule here stated, and proposes to make ^'■permeability 
an indispensable prerequisite to the performance of external division." He 
has some most respectable followers in this innovation, and, as a matter of 
course, many eminent and uncompromising opponents. The exclusiveness 
and ultraism, however, which formerly retarded the progress towards a rea- 
sonable investigation of the matter, are evidently giving way in the lapse of 
time to enlarged experience and calmer observation on both sides ; and 
the conflicting parties are approaching to a common ground which will prove 
more tenable than either of the positions so bitterly maintained at first. 

Mr. Syme and some others originally disbelieved in the existence of im- 
passable stricture.''^ In this the positive experience of several unquestionable 
observers is decidedly against them ; and even 3Ir. Syme himself has been 
obliged not only to C|ualify his first assertion, but to modify his individual 
belief. Mr. Thompson admits the possibility and actual occurrence of im- 
permeable stricture, but adheres to the opinion that it is so rare as to be 
practically almost unknown; and that, therefore, in the vast majority of 
cases, the ordinary mode of perineal section without a guide inserted through 
the seat of stricture, is re^ly unnecessary, as Mr. Syme avers ) while the 
" external division'' on the grooved sound suggested by the latter, may 
sooner or later be effected, and must be taken " as the rule." The real 
amount of permeability must vary in different hands and under different cir- 
cumstances in the same patient. It can only be approximatively determined in a 
number of exceptional cases already sufficiently large in the practice of undoubt- 
edly skilful operators to warrant the more difficult and dangerous operation, 
notwithstanding the remarkable success of Mr. Syme in overcoming the diffi- 
culty which necessitates a resort to it by others. The difference, after all, is 
more verbal than practical among competent men. Most assuredly,"' says 
Mr. Thompson, " the cases are few in which a sound may not be passed by a 
skilful and persevering operator, perhaps fewer than they have generally been 
supposed." A recent notice of the second edition, just published, of Mr. 
Syme's work On Stricture of the Urethra and Fistula in Perinea [Edin- 
burgh Monthly Journ. of Jled., for April, 1855), affords us the opportunity 
of quoting his latest experience in relation to this and other points at issue 
in the controversy. 

** Catting into the perineum without the assistance of a precise guide, ex- 
. poses to the serious danger of opening the urethra on the wrong side of the 
stricture, of breaking through the deep fascia and of wounding the artery of 
the bulb, so as to incur the risk of urinary extravasation and hemorrhage, 



100 



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[July 



while pressure being the only means available to suppress the latter, must 
greatly tend to promote the former evil. It is, therefore, no vronder that this 
procedure has been looked upon as a forlorn hope, warrantable only in cases 
of impermeable stricture. But while admitting, as I have already done, that, 
in some rare cases, the urethra may be actually obliterated, I maintain that no 
stricture is impermeable, and that if a drop of urine is able to escape, a director 
of suflu-ciently small size may be introduced ; and in support of this position I 
appeal to the fact that, although patients alleged to labour under impermeable 
contractions have come to me for relief from the most distant parts of Scot- 
land, England, and Ireland, from the Colonies and from America, I have never, 
either publicly or privately, been unable to pass an instrument since I became 
satisfied that there was no true impermeability.^^ 

** Some advocates of impermeability, indeed, allege that those who deny the 
existence of this condition effect a passage by force ; but as the stricture is 
tougher than the sound urethra, and as, therefore, any passage accomplished 
by force must necessarily be a false one, which would aggravate the patient's 
case instead of remedying it, the satisfactory result of treatment affords a most 
complete refutation of such statements. As already said, it is far from my 
intention to allege that the introduction of instruments may always be accom- 
plished with ease. In general, I have succeeded at the first attempt ; but in 
many cases have had to wait days, or even weeks, before the passage could be 
hit. Indeed, on three occasions — one in private and two in public — I found it 
necessary to open the urethra anteriorly to the stricture, so as to obtain the 
assistance of a finger placed in the canal, to guide the point of the instrument." 
(Pp. 33 — 36. See p. 331 of the Journal just quoted.) 

Mr. Syme's adversaries cannot fail to be much edified with the new method 
of insinuation which he rather naively announces as having at last to be 
resorted to before the passage " could be hit." Such an admission looks ex- 
tremely like a virtual surrender of his previous assumption, since it proves 
him to have been foiled, and ranges him inevitably with Liston and other 
champions of permeability, who have been weighed in the balance and found 
wanting. The manoeuvre, which is here only the prelude to the final incision, 
strikes us as closely resembling the anterior opening which Mayo in his Out- 
lines of Patliology (p. 404, Am. ed.) designates as a material part of the main 
procedure. It is most suspiciously like a "buttonhole" contrivance, and un- 
avoidably suggests the idea of a back door in the operator's argument. 

In one of the two cases that occurred in public, Mr. Syme, according to his 
reviewer, after mentioning that he had been for two months unable to pass a 
bougie through a stricture reported impermeable, gives the following account 
of the plan he adopted : — 

" As I had little doubt, however, that the difficulty arose from the form of 
the urethra where the false passage entered it, rather than from mere tightness 
of the stricture, I resolved to lay open the urethra on a director in front of the 
stricture, and then endeavour to guide the director through the stricture by 
means of my forefinger introduced into the wound ; for I had found, in a 
former case, that the tip of the index finger being inserted into the part of the 
urethra in front of the stricture as into a thimble, afforded the means of guid- 
ing on an instrument through the stricture with unexpected facility. Accord- 
ingly, on the 31st August, the patient being under chloroform, I measured with 
a large bougie the distance of the stricture from the external orifice, and having 
introduced a director rather larger than a No. 1 bougie for the same distance 
into the urethra, I pushed it in as far as it would go, and being thus sure that 
the end of the director was in the false passage, I made an incision in the 
middle line of the perineum, and laid open on the director the contiguous parts 
of the urethra and false passage. Having then introduced my finger into the 
wound, I succeeded in guiding the director through the stricture, and divided 
it in the usual manner by running the knife along the groove. I had now no 



1855.] 



Thompson, Stricture of the Urethra. 



101 



difficulty in passing a full-sized catheter into the bladder.'^ (Pp. 94-96, from 
Ibid. p. 331.) 

"This case/' as the journalist justly remarks, "appears to throw an entirely 
new light upon the subject of relieving retention of urine by operation when 
the catheter cannot be passed in the ordinary way. And, although Mr. Syme 
tells us that he has never yet found puncture of the bladder necessary for 
retention of urine depending upon stricture, he must admit that if a case like 
the above had come to him with urgent retention, before he had hit upon the 
expedient there made use of, he must have had recourse to puncture of the 
bladder. For though the difficulty in that case arose from complication with 
a false passage rather than from tightness of the stricture, yet it was not on 
that account the less insuperable in the ordinary way. The great obstacle to 
the management of strictures at the bulb unquestionably is the difficulty of 
guiding small instruments with precision in that part of the canal, and the 
means now furnished by Mr. Syme for facilitating this process appears to us 
a most valuable addition to surgery. — [Edin. Monthly Journ. of Med. 1855, pp. 
331, 332.) 

The forms of stricture which are described by Mr. Thompson as not amena- 
ble to the treatment by dilatation or other action within the canal, have been 
already briefly sketched. We may as well again avail ourselves of Mr. 
Syme's reviewer to quote that surgeon's graphic picture of the cases which 
his plan is intended to relieve. These — 

" May be distinguished as unyielding, irritable, and contractile. In the un- 
yielding form, dilatation, though it may be carried on to some extent, is sooner 
or later arrested by resistance of the tough texture at the seat of contraction; 
and if attempts are made to remove this obstacle by forcible distension, the 
most serious consequences are apt to ensue. In the irritable condition, while 
all the symptoms of stricture are presented in an extreme degree of severity, 
the gentlest introduction of instruments is sure to produce great aggravation, 
not only at the time, but for days afterwards ; so that the patient is distracted 
between the desire to obtain relief, and dread of the effects resulting from 
means employed with this view. In the contractile, or spasmodic stricture, as 
it is usually called, no difficulty is experienced in dilating the canal to its 
proper capacity ; but unhappily with little benefit, the patient still making 
water laboriously, painfully, and frequently by drops, or in a dribbling stream, 
which is liable to complete obstruction, through the influence of any local or 
constitutional disturbance affecting the urinary organs." 

" For the treatment of stricture in these three forms, whether existing singly 
or combined together, the means of remedy hitherto employed have proved 
quite unavailing ; and the patients thus afflicted are deserving to be regarded 
as a great discredit to surgery. If poor, they frequent hospitals until dis- 
missed by desire from despair of relief, or are declared incurable, or fall vic- 
tims to practice more zealous than discreet. If rich, they run the gauntlet of 
European skill, having bougies introduced, caustic applied, internal incisions 
inflicted, and so on, until, with broken health, disappointed hopes, and perhaps 
empty purses, they retire in dreary seclusion from society to carry on a dan- 
gerous and ineffectual system of palliation through means of the various appa- 
ratus collected in the course of their wanderings. That this is not an imagi- 
nary or overdrawn picture must be admitted by every practitioner who possesses 
any considerable field of observation, and will also appear from the cases to be 
found in any large hospital.'^ (Pp. 25, 26, from ibid, p. 330.) 

With regard to the alleged dangers of tho external incision, as performed 
by Mr. Syme — hemorrhage and extravasation of urine — Mr. Thompson is 
inclined, with Mr. Syme, to doubt them altogether as not proven by expe- 
rience. Hemorrhage may be escaped by adherence to the middle septum of 
. the bulb, and serious extravasation may be rendered equally improbable by 
limiting the external incision and avoiding the deep-seated fascia and the por- 
tion of the urethra posterior to the bulb. The only other risk is from purulent 



102 



Reviews. 



infection or pyaemia, which is not peculiar to this operation, or as great in it 
as in the old one. There is, however, a train of nervous symptoms, consist- 
ing of rigors, with occasional vomiting, suppression of urine, and delirium, 
which become at times alarming, and may give rise to great anxiety and suf- 
fering during the first two or three days. Mr. Syme insists that they are 
transient in the great majority of cases, passing off in a few hours without 
the slightest disagreeable consequences.^' 

The principles on which this operation is founded are summed up in a re- 
cent lecture of Mr. Syme, published in the London Lancet, in the following 
terms : — 

*' First. Stricture is never seated posteriorly to the bulb, and tlierefore the 
incision should never extend farther back than the bulb. 

*' Second. A grooved director must be insinuated through the contracted 
part, without injury or abrasion of the lining membrane of the urethra. 

" Third. If the incision has been properly performed, there is no need to 
dilate sinuses, which are sure to close when the stricture is removed. 

"Fourth. A catheter should be introduced into the bladder after the opera- 
tion, and retained for forty-eight hours ; not less, on account of the risk of the 
extravasation of urine ; and not longer, because it is unnecessary, and apt to 
do harm.'' (March, 1855, p. 198.) 

We do not believe that Mr. Thompson would endorse the above sweeping 
assertion that strictures are never posterior to the bulb. Mr. Syme makes 
this negative statement on the ground that in all his operative experience, 
which, at the date of his last edition, amounted to 108 cases, he has never 
had reason to cut further back than the bulbous portion. 

The original anticipations of its author in respect to freedom from danger 
to life in the operation of Mr. Syme, appear to have been entirely fulfilled in 
his own experience, as well as in the results ascertained by Mr. Thompson. 

" Having declined no case presented for treatment, and operated at all ages, 
from 77 downwards, as well as under every variety of complication from long 
existence, alleged impermeability, and the false passages of previous misma- 
nagement, I have now performed the operation 108 times, with only 2 fatal 
results that can be ascribed to it.'' (Pp. 44, 45, Journ. citat. p. 333.) 

Neither of the fatal cases (attributed to pyemia) appears to the Edinburgh 
reviewer to be very clearly made out against the operation, since the one was 
not a fair subject for operation, and the death in the other was probably the 
result of cerebral lesion. Two cases in over a hundred is a sufficiently small 
proportian to satisfy every candid reader, whether fairly counted or not in 
the estimate of liabilities. Mr. Thompson's table gives 113 cases and four 
deaths, also from pyaemia. We give the table of Mr. Thompson for what it 
is worth, although, as far as the general results are concerned, we would put 
more faith in his individual experience, and in that of the original performer, 
than in that of a number of different experimenters, however able, unless we 
. could be sure that the manipulation and general management were the same, 
cseteris paribus, in all the cases. 

By Mr. Syme, above 70 times, no death ; a large proportion of the cases suc- 
cessful. 

By Mr. Fergusson, 4 times ; 1 death ; 2 tolerably successful ; 1 doubtful. 

*' Outlines of Cases," Nos. 1 to 4. 
By Mr. Cock, 5 times ; 1 death ; the remainder more or less successful. 

" Outlines of Cases," Nos. 5, 6, 7, 8, and 9. 
By Mr. Coulson, 8 times ; 1 death ; the remainder more or less successful. 

" Outlines of Cases," Nos. 10 to 17. 
By Mr. Erichsen, 5 times ; the majority more or less successful ; one or two 

doubtful. Outlines of Cases," Nos. 18 to 21. "Reported cases," No. 17. 



1855.] 



Thompsoiij Stricture of tlie Uretlira. 



103 



By Mr. Haynes TValton, 1 time ; successful. Outlines of Cases," No. 22. 

By Mr. H. Thompson, 1 time ; successful. " Eeported Cases," No. 11. 

By Mr. Mackenzie, 7 times ; one death ; the remainder more or less successful. 

" Outlines of Cases," Nos. 23 to 29. 
By Mr. Dunsmure, 3 times ; two more or less successful ; one unsuccessful. 

Outlines of Cases," Nos. 30 to 32. 
By Dr. F. Thompson, 2 times ; successful. " Outlines of Cases," Nos. 33, 34. 
By Dr. Cruickshank, 1 time ; successful. " Outlines of Cases," No. 35, 
By Mr. Fiddes, 6 times ; five successful; one doubtful. " Outlines of Cases," 

Nos. 36 to 41. 

An examination of the detailed histories of these cases does not convince 
Mr. Thompson that any great danger was incurred from hemorrhage ] cer- 
tainly not more, if not less, than in other operations involving any portion of 
the urethral bulb. At all events, in the opinion of our author, if bleeding 
should come on, it can always be arrested. Only one instance of hemorrhage 
occurred in Mr. Syme's 108 cases. 

In answer to the question as to how far external incision should be en- 
titled to acceptance as a standard remedy for the specified forms of stricture, 
Mr. Thompson gives, as much as present limited experience will justify it, a 
favourable answer. We must refer to the essay itself, and to Mr. Syme's 
various articles, for an enumeration of the different causes to which they at- 
tribute failures and relapses. To these, also, and especially to Mr. Thomp- 
son's admirable account of it, would we invite the careful attention of our 
readers for an unmistakably precise and full description of the various practi- 
cal details of the operation and the instruments employed. 

The chapters on " Urinary Abscess and Fistula," on Eetention of Urine 
depending on Stricture," and on ^' Stricture of the Female Urethra," occupy 
the remainder of the regular work. They are, like the others, full of valuable 
information, and may be consulted with signal advantage by every one in 
search of guidance in the management of those formidable classes of disease. 

The second of these final chapters closes, " in pursuance of the principle 
which has been adopted in regard to each section of this work," with a brief 
recapitulation of the conclusions arrived at in relation to the entire sub- 
ject of treatment, in order to afford a summary of the main points which it 
has been my aim to elucidate in the foregoing pages.'' 

We quote them in full as they follow : — 

" 1. That the process of dilatation, carefully and perseveringly employed, is 
the most safe, efficient, and generally applicable of all means for the treatment 
of organic and permanent stricture." (Pp. 173-4.) 

" 2. That, while it is successful in curing the majority of cases, there are 
unquestionably some in which either the effect is so temporary that the con- 
traction reappears on the cessation of the treatment, however long continued, 
or in which the urethra is so irritable that its employment aggravates rather 
than removes the symptoms." (Pp. 205, 255-6.) 

" 3. That the nitrate of silver lightly applied is sometimes useful in the last- 
named cases, inasmuch as it exerts a salutary influence upon the diseased 
surface of the urethra, relieving inordinate irritability, and checkino- undue 
vascularity and disposition to hemorrhage, as it does in similar conditions of 
the skin and mucous membrane in other parts of the body, and that it is a use- 
ful adjunct to dilatation." (P. 219.) 

" 4. That the potassa fusa, as a caustic, is considerably more active than the 
preceding, and is therefore more dangerous of application. If used at all, it 
should be applied only in very minute quantities, inasmuch as it is exceedingly 
difficult to limit the action of so powerful an escharotic, and apply it as a solvent 
only. It appears occasionally to aid the process of dilatation in the reduction 
of some strictures, probably by facilitating the solution of their component tis- 



104 



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sues, ■when care is taken to employ it in obedience to the condition just named." 
(P. 220.) 

5. That no agent should be employed in any case for the purpose of making 
an eschar or slough in the urethral canal." (P. 220.) 

" 6. That internal division is applicable only to strictures which are situated 
in that part of the urethra which is anterior to the bulb, and which have been 
found to resist dilatation." (P. 225-6.) 

" 7. That the distance at which a stricture is situated from the orifice, and 
the extent to which it implicates the canal, may be so great as altogether to 
forbid the practice of internal division ; for the operation becomes more hazard- 
ous just in the ratio of the extent of the stricture, and extent becomes more 
formidable in the ratio of its distance from the external meatus ; so that it is a 
far easier proceeding to make external division of a large portion of contracted 
urethra situated in the anterior part of the spongy body, than of a small por- 
tion at the bulb or behind it." (P. 234.) 

" 8. That dilatation having failed after an ample trial, the stricture being 
permeable and situated near to the junction of the bulb and membranous por- 
tion (a spot already seen to be the most frequently affected), external division 
made from the perineum upon a grooved staff is, for most such cases, a safe and 
efi&cient mode of treatment." (Pp. 256, et seq.) 

" 9. That when the urethra is impermeable, every available means having 
been patiently and perseveringly employed to pass a catheter through it, but 
without success, the perineal section may be performed as a means of cure.'' 
(Pp. 251-2.) 

" 10. That when it is necessary to make an artificial outlet to relieve reten- 
tion of urine, an operation may be performed for the purpose of curing the 
stricture at the same time ; but if the condition of the patient require the pro- 
ceeding employed to be as simple as possible, the puncture of the bladder per 
rectum is indicated, unless the urethra be dilated in the perineum, when the 
making a single puncture there will be the best operation to perform.'' (Pp. 
308-9.) 

"That it is a matter of great importance in the treatment of old or severe 
strictures, in relation to the mode of treatment employed, to ascertain what 
degree of organic renal disease exists as fully as our means of observation 
enable us; inasmuch as its presence renders all operations upon the urethra 
hazardous, and, for the most part, in a degree corresponding with the extent 
to which the renal organs are implicated." (Pp. 102-3, and 269.) 

" 12. That since few permanent strictures exist, which are not considerably 
influenced at some time or another by the occurrence of inflammation or con- 
gestion in the parts around, or by the action of spasm in the adjacent muscular 
tissues, either separately or conjointly, treatment may be always most advanta- 
geously directed to the improvement of the general health, to the subduing of 
local congestion, and to the removal of those sources of irritation, whether in 
the urine, in the urinary passages, or in some other and more distant parts, 
which have been pointed out as liable to excite the phenomena referred to." 
(Pp. 203-5, and Chapter V., The Pathology of Strictures which are of Transient 
Duration.) 

Last, but not least, our author treats us to an appendix, which is in itself 
a rich and extremely interesting book. It is a nearly inexhaustible mine of 
practical instruction in its abundant and varied record of clinical and patholo- 
gical facts. As such, we recommend its frequent study to both students and 
practitioners. They could not more effectually improve themselves in their 
application of the principles so amply and distinctly developed in the previous 
pages of the volume. 

Urethral stricture, of all the ills that flesh is heir to, does most notoriously 
expose its victims to the charlatan and the sciolist. A really sound essay, 
therefore, which covers the whole ground with the ability and candour of the 
one before us, ought to be welcomed as a more than ordinary boon to erring 
humanity. It cannot be denied that, however copiously and wisely the sub- 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



105 



ject has been dealt with by authoritative teachers from the time of Pare and 
Wiseman until the present day, the thirst for gain and novelty, the spirit of 
ambition and adventure, are ever actively engaged, with often reckless and 
fearfully mistaken zeal, in devising new means and appliances for casting off the 
burthen of misery under which so many impatient sons of Adam are in this 
way doing penance for their sins. A contribution of the character and standing 
of Mr. Thompson's, should for its beacon-light alone be cherished as a work of 
peculiar necessity and value. Its appearance, along with that of a few others 
of similar tone and tendency, will be prized as the best evidence of decided 
progress in this branch of surgical pathology and therapeutics ] since they 
are founded on the only true basis of extended personal observation and 
research. E. H. 



Art. XIY. — Inquest on the Death of Agnes E. Lottimer, before Dr. GtEORGE C. 
Ball, Coroner, Brooklyn, N. Y. New York, 1854, pp. 44, 8vo. 

It is not often that we have an opportunity of seeing quackery brought to 
such tests as will reveal its true character. Its system of deceptions ordina- 
rily suffices to keep the public in ignorance of its falseness and its folly. But 
now and then the true tests are applied, and quackery is drawn out from its 
concealment, and its false pretensions and dishonest arts are exposed to the 
light of day. The coroner's inquest contained in the pamphlet before us 
has' done this for that ridiculous but genteel form of quackery commonly 
called homcBopathy. So far as one single case can do it, the case here re- 
ported exhibits in the clearest manner the ignorance and folly which belong 
to homoeopathic practitioners of even high repute among its advocates, and 
the degrading influence which the beliefs and practices of homoeopathy exert 
upon the mental character, and we may say upon the moral character also. 
We propose, therefore, to develop to our readers in this article, the character 
and tendencies of homoeopathy, as they are exhibited to us in this case. 

The facts of the case are briefly as follows : Agnes E. Lottimer, aged 12 
years, was taken sick on the 2d of August. She was attended by Dr. Wells, 
a homoeopathic doctor in Brooklyn, N. Y., with Dr. Dunham, another 
homoeopathic doctor, in consultation occasionally. From the account which 
Dr. Wells gives of the case, it appears that the disease was intermittent fever. 
Both the physicians and the quacks that testified in the case agree on this 
point. The only difference of opinion was as to its accompaniments and 
complications. These will be spoken of in the course of our remarks. 

Although the disease lasted so long (over two months), the homoeopathic 
doctors assured the anxious parents and friends that the patient was doing 
well, because, as they testified, the paroxysms were becoming shorter and less 
severe. To convince the anxious father that they were right. Dr. Dunham 
read to him from Kunstadt (we suppose some voluminous driveller in homoeo- 
pathic nonsense), thinking that he must, of course, be satisfied with what is 
put down in one of their books. But this was not satisfactory, for the parents 
had just lost a son that had intermittent fever under the homoeopathic treat- 
. ment of Dr. Wells, and a beloved daughter was now suffering under the same 
disease, which a continuance of homoeopathic medicines for weeks had not 
suflaced to arrest. The parents were^ of course, exceedingly anxious about 



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the result. Mrs. Lottimer says, " I nearly daily, during my child's illness, 
expressed strong anxiety about her. I said I thought my child was not get- 
ting better, and that they let the chills last too long. This was both to Dr. 
Wells and Dr. Dunham. They said they would soon break them, and they 
expected every day they would slip by; that I need not feel uneasy, Agnes 
would get well.^' Her anxiety at one time, about three weeks before the 
death of the child, was so great that she sent for Dr. Dunham for the pur- 
pose of expressing her feelings to him, because she thought that she saw 
alarm in Dr. Wells's countenance, though he said nothing. But he told her 
that there was no cause for solicitude. It seems that Dr. Wells put his ear 
to the chest twice during this long illness, probably suspecting from the 
breathing that there might be difficulty there. The second time that he did 
this, Mrs. Lottimer says that she asked Dr. Dunham " if there was any con- 
gestion about Agnes's heart or lungs, or any other vital part; and he said I 
was nervous and unnecessarily alarmed; that there was nothing of the kind; 
she was all right. Me did not make any examination whatever previous to 
answering me." Propositions were made to call in some other physicians, 
but Drs. Wells and Dunham told the parents and friends that this was wholly 
unnecessary. At one time the parents and Mrs. Lottimer's brother decided 
to call in another physician, and fixed upon Dr. G-ray. It was proposed to 
Dr. Dunham, but he had the old story, that there was no need of further 
advice — she is all right'' And he added, that if further counsel were 
needed, he certainly would not select Dr. Gray, because he did not practice 
this system (how many systems are there ?) of homoeopathy. 

And so, although the disease was going on week after week, it was all 
right, all right, till at length the patient was suddenly worse. The conges- 
tion which the anxious mother suspected, but which Dr. Dunham, without 
any examination, assured her did not exist, was suddenly largely increased, 
convulsions and hemorrhage ensued, and in a few hours the patient died. 

Of course, the death must be accounted for in such a way as to satisfy the 
friends of the patient, and save the reputation of the quacks who had treated 
the case, saying all right, all right, up to the very last day of her life. The 
common, we may say the old, trick of quackery was resorted to for this pur- 
pose. The death was attributed not at all to the disease treated, but to an- 
other disease that "set in," as it is vulgarly expressed. This disease was the 
mumps, which, according to the homoeopathic doctors, destroyed life in this 
way. It was unfortunately translated to the hrain, and so produced the con- 
vulsions; and then, either the convulsions caused a congestion of the lungs, 
or the mumps experienced a second translation — from the brain to these 
organs. 

These, with various other attendant explanations, would probably have an- 
swered the purpose very well, if they had merely been talked over in the 
usual indefinite way by the homoeopathic doctors and their believers. Now 
and then, it is true, they would have come to the ears of some " allopathic" 
doctors, as these homoeopaths are pleased to style rational physicians, who 
would be so uncandid as to pick some flaws in the anatomy and pathology 
exhibited in these explanations. But after all, the quacks (for by no other 
name can we properly designate them) would have had it very much their 
own way, and the Lottimer family, and all the believers in homoeopathy, 
would probably have been satisfied with the seemingly learned and plausible 
views of the case presented by Drs. Wells and Dunham. Unfortunately for 
them, however, the case was not to be disposed of in this quiet way. Their 
plausibilities were not to be left to go unexamined. An examination after 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



107 



death was made by several physicians. And then a coroner^s inquest was 
held, and all the facts of the case, together with the explanations of the 
homoeopaths, were fully brought out. Not only were Drs. Wells and Dun- 
ham thoroughly exposed, but the false and nonsensical character of homoeo- 
pathy, entitling it to the appellation of a system of quackery, was exposed 
also. 

In order to prevent this exposure from having its legitimate effect on the 
community, a garbled report was prepared by a homoeopathist, and was pub- 
lished, which is just such an expedient as we should expect from such a 
source. To say nothing of other omissions and misrepresentations in this 
report, a monstrous blunder in pathology committed by Dr. Wells, in 
accounting for the hemorrhage in the case, was entirely omitted, although it 
was really a prominent point in Dr. Wells's testimony, as the reader will 
soon see. 

In the pamphlet before us, we have a full report of the testimony in the 
case, without note or comment, as it was taken down at the time. There are 
some parts of this testimony which we propose now to examine. 

Dr. Wells's testimony is very full. He utters his nonsense about the 
pathology of the case and its treatment with a grave and learned air. He 
comments in extcnso upon the effects of the remedies that he used, which 
were many, viz : aconite^ helladonna^ rJius toxicodendron , Pulsatilla^ sulphur, ar- 
senicum, carho vegetalis, veratrum album, ipecacuanha, nux vomica, cinchona, 
calcarea carhonica, cedron, opium, cicuta. All these he gave in infinitesimal 
doses, and besides, he gave coffee and lemon-juice in " allopathic" doses ; 
why, he does not inform us. If the jury were enlightened at all by his com- 
ments on these remedies, they were more fortunate than we have been. 
There is a show of wisdom in them, which was intended to have its effect on 
the jury, and probably had. We suppose that they really were impressed 
with the great and discriminating knowledge of Dr. Parkhurst P. Wells in 
the Materia Medica Pura of Hahnemann. We give an extract from this 
part of the testimony. 

'* The ague of veratrum is made up more of chill than fever, the chill also 
accompanied by a cold perspiration — this she got after the night of the 10th. 
The ague of arsenic has so many varieties that I could not repeat them without 
getting the book and reading. Ipecac produces vomiting, perspiration, cramps 
in the stomach, &c. Ague and fever without thirst, ipecac will very likely 
cure. Probably at that time her fever and ague was unaccompanied with 
thirst. I judged it to be the very best thing she could take when I gave it, 
because the symptoms she had corresponded with the symptoms the ipecac 
would produce. I do not remember them now. All the symptoms produced 
by ipecac are not found in the same person; they are modified by age, tern-;' 
perament, sex, &c. 

Nux Vomica. Thirst from the beginning of the chill, continuing through 
the chill, also through the fever, pains in the head through both chill and 
fever ; it is also applicable to paroxysms occurring any time within the twenty- 
four hours; thirst ceases at the cessation of the fever. It is probable that this 
was the form of fever at the time this was prescribed; this was given in the 
one-third centesimal, and in the same form, every two hours, repeated during 
the intermission. 

Pulsatilla produces fever, leucorrhoea, amenorrhoea, dysmenorrhoea, nausea 
and vomiting, diarrhoea, &c. 

I do not remember exactly why I gave this, further than the general state- 
ment already given. The same dose as the others. 

. Cinchona, the same dose. I do not remember the form of ague in this par- 
ticular case. 



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Calcarea Carhonica was given in the same dose, and for some other form of 
the fever which I do not recollect. 

Cedron is a kind of bean that grows in tropical regions ; the properties are 
not proved, or fully understood. I took it myself in health, and got chills 
affecting the left side of the body, and in the afternoon, pains in the stomach 
and in the forehead and over the eyes ; darting pains in the right arm first, 
and in the left the second, along the ulnar, and also in the right hand. I do 
not remember the particular state of the patient for which this was given; her 
paroxysms were very much mitigated by its effects, so much so that I expected 
every day she would pass her chill. She continued its use perhaps ten days; 
nothing else given at the same time.'' 

The reader will observe some strange failures of memory here. Although 
Dr. Wells gave cedron^ for example, for ten days, he does "not remember 
the particular state of the patient for which this was given.'' Neither does 
he remember why he gave ipecacuanha^ pulsatillaj cinchona, and calcarea 
carhonica. And he is entirely in the fog about ar&enic, or arsenicum, as all 
the lady-homoeopathists are careful to call it. He informs the jury that he 
could not enlighten them about this "without getting the book and reading." 
If he had been requested to do this, we should like to have looked at that 
jury while he read to them the description of the effects of arsenic from that 
standard work, Jahr's Manual, filling over four large closely printed pages, 
with such ridiculous minutiae as these : " Muddled and heavy head in the 
house, relieved in the open air. Headache alleviated by putting on cold 
water, but aggravated when removing it. Religious pensiveness; fear of 
spectres and thieves; warts j attacks of rheumatic pains continuing six days, 
with intervals of four days. When lying, one feels strong and wishes to get 
up, but upon doing so sinks together. Desire for acids, or whiskey, or coffee. 
Great anxiety in the evening after lying down, or at 3 o'clock in the morn- 
ing when awaking," &c. &c. But we pass on to graver matters. 

Dr. Wells's idea of the case was in the beginning that it was inflammation 
of the membranes of the brain. But in about eight days under his treat- 
ment she was cured, or, as he would say, healed of this. Then came on sud- 
denly a state of things thus described: "On the night of the 10th of 
August, about 10 o'clock, I was called by a messenger, who said she was 
much worse, and they thought she must die. I found the surface cold, pale, 
and covered with perspiration. Pulse 160 in a minute, small and weak; 
great thirst, restlessness and anxiety, and much tossing about the bed, and 
anxious respiration. She was unconscious." He does not explain at all this 
state of things, but he says, that for ten days after this, the case " was ague 
and fever without intermission; there was not sufficient vital power to bring 
about an intermission. After that ten days it became a regular intermittent, 
and so continued uncomplicated up to three days before her death, and then 
continued up to her death complicated with mumps, which was translated to 
the membranes of the brain." This translation of the mumps, he supposes, 
caused a "congestion of the brain," and this produced spasms. Then, to 
crown all, there was another metastasis of the mumps, it going this time to 
the lungs, and death was the result. 

Before commenting on these and other opinions of Dr. Wells, let us look 
at the result of the post-mortem examination. It was made by Dr. James 
R. Wood, of New York, in presence of Professors Willard Parker, and 
Chandler R. Grilman, of New York, and Dr. Dudley, of Brooklyn. The 
account of it, as given by Dr. Wood, is as follows: — 

"Upon an external view of the body there was nothing peculiar, excepting 
an extraordinary quantity of adipose matter or fat. The skin was of a dirty 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



109 



white hue. The eye only peculiar from its life-like appearance. Its mem- 
branes appeared natural. The eye was normal. I made a section of the 
scalp; found nothing peculiar, except that not a drop of blood followed my 
scalpel. On removing the calvarium, the external membrane of the brain, the 
dura mater was pale and healthy. Upon removing the superior portion of this 
membrane, the second or arachnoid membrane was brought into view; it was 
opaque, and thickened at points in the course of the longitudinal sinus; be- 
neath it was an effusion of serum, to the physician known as subarachnoid 
effusion. This membrane was healthy in other parts of the brain. A third 
or vascular membrane, the pia mater, was thickened, congested, and could be 
removed in considerable portions by slight traction with the forceps in the 
neighbourhood of the opaque and thickened arachnoid. This tissue in other 
regions of the brain was healthy. Upon making a section of each hemisphere 
of the brain, the parts were found healthy. Upon cutting into the ventricles, 
the organs there contained were healthy. There was a small quantity of serum 
in each ventricle, which, in my opinion, was post mortem ; other parts of the 
cerebrum healthy. The cerebellum was healthy. Upon dividing the medulla 
spinalis, and removing the brain, there was discovered a considerable quantity 
of serum in the spinal canal, also a considerable quantity in the fossa of the 
occipital bone. This was placed in a tumbler, and estimated to be about three 
ounces in quantity. On making a section of the integuments from the upper 
portion of the sternum to the pubis, nothing peculiar, except the enormous 
quantity of fat, by measurement from the integuments to the tendon of the ex- 
ternal abdominalis muscle, one and an eighth inch. On raising the sternum, 
and looking into the cavity of the left pleura, a considerable quantity of bloody 
serum was discovered ; it was removed and estimated at from three to four 
ounces in quantity. In the right pleura there was also bloody serum, esti- 
mated at about or little more than an ounce. The pleura covering the lungs, 
and that lining the thorax, intensely congested ; the lung barely crepitating 
throughout. An old adhesion between the middle and inferior lobe of the 
right lung. Upon examining the heart and its envelops, they were found 
healthy ; very little or no blood in the heart; a small quantity of serum in the 
pericardium. Upon removing the lungs from the cavity of the thorax, and 
making an incision at different points, they were found to be intensely con- 
gested with blood. So heavy were they, that they would barely float in water. 
Upon examining or laying open the large bronchial tubes, they were found 
empty, with their lining, or mucous membrane, intensely congested, of the 
colour of mahogany. In tracing down the smaller tubes, they were also con- 
gested, but contained bloody serum. In other respects, the thorax healthy. 
Upon opening the abdomen, parts of the viscera, which presented themselves 
to view, presented no other peculiarity except that of being almost bloodless, 
with the exception of the liver, which appeared much darker than natural. 
This organ, upon being cut into, was found to be almost bloodless. It was 
healthy, and its appendages, including the gall-bladder, also healthy. The 
spleen was found to be many times its natural size by measurement ; eight 
inches the longest diameter, and four the transverse; by weight, one pound; 
very little blood, if any, followed the scalpel. In making a section of it, its 
colour was the colour of the ordinary blue plum. Requested by the coroner, 
I applied ligatures to the two orifices of the stomach, which was taken by him 
for chemical analysis. The kidneys examined externally, the colour very 
much like that of the spleen. Upon making a section, they were found to be 
very much congested, and presented to view a pathological condition of this 
organ known as Bright's disease, or granular kidney, in its first stage. The 
two weighed eight ounces. The pancreas, large and small intestines, the blad- 
der, and other organs of the abdominal and pelvic cavity, were examined and 
found healthy." 

The following are some of the opinions which Dr. Wood gives upon these 
appearances. 

"It was my opinion that the opaque and thickened condition of the arach- 
noid membrane was the result of inflammation, and that inflammation not of a 
No. LIX.— July 1855. 8 



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recent date — perhaps of some weeks' standing. I also account for the patho- 
logical change of the pia mater in the same way. The serum was the result 
of prior disease ; much of it from the congested condition of the vessels of the 
pia mater. Some of it was post mortem. 

*' The lungs were congested. From the evidence of Dr. Wells, there can be 
no doubt that this patient was suflPering from the poison of marsh miasma. 
From the post mortem appearances, it is my opinion that they were produced 
by the effects of that poison on the system. The enormous size of the spleen, 
the colour of the liver, the intense congestion of the lungs, and the history of 
the case, warrant me in giving this as my opinion. 

" The blood thrown up undoubtedly came from the lungs. It was in this in- 
stance, in my opinion, an effort of nature to relieve the lungs of .the super- 
abundance of blood which they contained. From experience we know that 
when large quantities of blood are thrown into the lungs, and that they are 
not able to rid themselves of it, the respiration of course is interfered with ; the 
patient dies either of congestion of the lungs, or of what is called pulmonary 
apoplexy. Here, as I have said before, I believe that the hemorrhage was an 
effort of nature to rid the lungs of the blood they contained, and that the pa- 
tient died of the loss of blood.'' 

These opinions were coincided in by the physicians who attended the ex- 
amination, and by Professors Alonzo Clark and J. M. Smith, and Dr. John 
Watson, who gave their opinion upon the testimony as they heard it. 

It will be seen that upon one point in the case there is an agreement be- 
tween Dr. Wood and Dr. Wells, viz : the existence of inflammation of the 
membranes of the brain at the beginning of the sickness. We have but a 
single remark to make in regard to this. If this inflammation had been met 
with the proper remedies, instead of being left to the recuperative efforts of 
nature alone, the probability is, that the inflammation would have been 
wholly overcome, and no such results would have been left in the brain as 
were found in the post-mortem examination. Giving the infinitesimals of 
homoeopathy in such a state of things is not merely ridiculous trifling ; it is a 
trifling with life, which cannot but stir one with indignation who knows how 
utterly without effect such doses are. As it was, a chronic disease was left 
in the brain, which ^.mdoubtedly had a share in bringing about the fatal 
result. Such a chronic disease, although generally manifesting itself more 
or less by characteristic symptoms, physicians well know sometimes exists 
without exhibiting these symptoms with any clearness. And yet we cannot 
help suspecting that Dr. Wells, who shows in his testimony such looseness of 
views, and such random, and fairly nonsensical reasoning, really failed to see 
symptoms that ought to have revealed to him this difficulty. But this we 
will not dwell upon. There are other points in the case in which he more 
palpably failed than in this. Some of these relate to the treatment, and 
some to the pathology of the case. A few of these we will notice. 

Here is a case, which, according to Dr. Wells' own admission, was uncom- 
plicated intermittent fever for over six weeks, and which was probably essen- 
tially this disease from the beginning of the case, that is, for over two months. 
And yet all this time he administered his high dilutions except for two days. 
And then he directed "a cup of black coffee and a tablespoonful of lemon- 
juice.'^ A strange overturn this in his practice! Why he did not give 
these remedies in infinitesimal doses he is not pleased to inform the jury. 
We may show an ignorance at which Dr. Wells and his learned compeers 
may laugh, but really we cannot see why coffee and lemon-juice should be 
given in doses millions upon millions of times larger than other remedies. 
According to Dr. Wells' common mode of dosing, here was coffee and lemon- 
juice enough to suffice for all the cases of intermittent fever that have been 



1855.] Inquest on the Death of Agnes E. Lottimer. Ill 

or will be in all time. And yet it must all be poured down the throat of 
this little girl twelve years old at one time I 

But ridiculous and supremely trifling as is this infinitesimal dosing with 
the interlude of large dosing, it is not the worst of the case. No fact is 
better established in medicine, by an abundant and long-continued experience, 
than that intermittent fever may in almost all cases he arrested hy medicine 
both sj^eedily and safely. And yet, in face of this established fact. Dr. Wells 
let this little patient go on suffering week after week from the congestion 
produced by the paroxysms, till at length the fatal congestion was fastened 
upon the lungs. Whatever other causes may have helped to insure the fatal 
result, this congestion thus produced by the intermittent fever was clearly the 
chief cause of death. 

Homoeopathists admit that cinchona, or its active principle, quinine, is capable 
of arresting the paroxysms 5 but they claim that it does not cure or heal (their 
favorite word) the disease. The malady, they say, reappears in the same or 
another form. And they pretend that the homoeopathic remedies do actually 
heal the disease — that they eradicate it wholly from the system by a gradual 
process, so that it cannot reappear. The truth is, that in all those cases in 
which recovery takes place under their system of high dilutions the disease 
simply wears out. That this will occur in some, perhaps we may say a con- 
siderable, proportion of cases, is well known from what is observed in some 
communities, where there is much prejudice against taking anything to arrest 
the disease. But in how large a proportion of cases this recovery by the 
recuperative energies of nature will take place has not been ascertained. We 
do not care to ascertain it, so long as we have a remedy which so safely 
arrests it, and saves our patients from the suffering and the risk that attend 
a continuance of the disease. 

In the practice of homoeopaths there is often much cheating in the treat- 
ment of this disease. Many cases are actually healed by quinine, and yet are 
reported to be cured by homoeopathy. A patient who had not been inducted 
into the mysteries of homoeopathic management, and who knew little of 
homoeopathy but its name, was boasting of being cured of intermittent fever 
by this system of practice. On being questioned as to what medicines ha 
took, he said that he did not know, but the powders which the doctor gave 
him were awfully bitter. Such cases of relinquishment of true homoeopathy 
are, we apprehend, by no means uncommon. Indeed, some homoDopathie 
doctors use quinine in large doses uniformly in the treatment of intermittent 
fever. This is the case with Drs. G-ray and Hull, two homoeopaths of some 
celebrity in New York, who testified in regard to this case. Dr. Gray says : 
" My dose of quinine varies from an eighth of a grain to two grains,^' Dr. 
Hull says: ^'I vary my dose from the y^o*^ ^ grain to a grain and, a 
half or two grains.^' We do not admire the honesty of such a course. To 
call themselves homoeopathic physicians, and yet give such doses, is cer^tainly 
setting up false pretensions. 

In the case before us, there was surely time enough given to the trial of 
the boasted eradicating process; and as it did not succeed, common pru- 
dence should have dictated a resort to a process in which the great body of 
the medical profession, however variant their views on other points, have had 
confidence more than two hundred years. It seems that the failure of the 
eradicating process did produce in Dr. Wells' mind a willingness to employ 
some other measure. Why, then, did he resort to the comparatively doubtful 
remedies, black coffee and lemon-juice, when the sure remedy, quinine, was at 
hand ? The most charitable construction we can put upon this, is, that he 



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[July 



was so strongly wedded to his exclusive notions that he would not consent to 
adopt a remedy so highly approved of by the hated " allopaths.'' It was 
slavery to a system that forbade his using the quinine — a system that has but 
one doctrine, and ignores all facts that militate against this sole law, though 
they may be established by the experience of ages. 

It is in the point just referred to that rational medicine and homoeopathy 
are at antipodes to each other. Rational medicine has no one law of cure. 
It has many. And not only so, but it is not confined to these many laws, 
but goes beyond them, and adopts remedies that it cannot bring under any 
general law of cure. It is ready to adopt anything which is curative, whether 
it can explain its modus operandi or not. The mode in which quinine cures 
intermittent fever it cannot explain, and therefore cannot classify it under 
any law of cure. It knows the bare fact that it will cure, and so adopts it; 
and it is ready to adopt anything, even infinitesimal dosing, if it only be 
proved to cure. It has no exclusive system of doctrine or practice, as the 
term allopathy, so gratuitously and falsely bestowed upon it by the homoeo- 
paths, would imply. But it is otherwise with homoeopathy. This rejects 
everything that manifestly disagrees with its " sole law of cure." It is for 
this reason that it rejects quinine in the treatment of intermittent fever, 
although the proof that it cures this disease is beyond all question. 

In looking at the symptoms of the case before us, its treatment, and the 
■revelations made to us in the post-mortem examination, we are fully war- 
ranted in saying that if the appropriate means had been used, this patient 
would probably have recovered. If the proper means had been used at the 
outset to overcome the inflammation of the brain, probably do chronic disease 
would have been left there to complicate the intermittent fever. And then, 
if the quinine had been used, it would have readily overcome the malady 
thus relieved of its complication, and the little patient would have been saved 
from the fatal congestion, which this long continued endurance of the parox- 
ysms at length produced. 

But it is claimed by Dr. Wells that the intermittent fever did not cause 
death, and that this result was produced by the mumps. This disease all the 
homoeopaths testified was translated to the brain. Dr. "Wells goes a little 
further than his brethren, and supposes a second translation, to the lungs. 
This he supposes to be the cause of the congestion there. For he says : "The 
congestion of the lungs might have arisen from one of two causes; first, the 
mechanical efl'ect of the embarrassed respiration (t attach no particular im- 
portance to this, the probability is the other way) ; and the other, metastasis 
of the mumps from the brain to the lungs." His brethren seem to lay great 
.stress upon this "mechanical effect of the embarrassed respiration" produced 
by the convulsions as the great cause of the congestion ; and they speak of 
it as if convulsions ordinarily produce congestion in those organs. And yet 
all experience is against such an assumption. There may be convulsions 
long continued, and yet, if the patient recover, there is ordinarily no conges- 
tion of the lungs as a result ; or if he die, there is ordinarily none found there. 
If it occur, it is the result of some other cause, and not the consequence of 
the convulsions. The homoeopaths have put the consequent in place of the 
antecedent, the effect in place of the cause, as they are very wont to do. The 
congestion was undoubtedly the cause and not the result of the convulsions, 
the chronic disease in the brain helping of course to produce the result. This 
is a common sense rational conclusion drawn from the history of the case in 
view of the pathological experience of the profession. But the common 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



113 



sense rational view is not the view to be taken of anything by the dreaming 
and exclusive homoeopathists. 

There is another point in the homoeopathic pathology of the case that de- 
serves a passing notice. There was blood discharged from the mouth and 
nose of the patient just before death in quite a large quantity, so large that 
she was supposed to die from suffocation by the accumulation of the blood 
in the throat. The homoeopathic doctors speak of this as resulting from a 
rupture of some bloodvessel caused by the convulsions. They speak of it as 
if rupture were common in hemorrhage. They do not seem to be aware of 
the well established fact, that in hemorrhage from the lungs the blood is 
poured out by innumerable little vessels on the surface of the mucous mem- 
brane, and that very seldom does any rupture of a bloodvessel occur in those 
organs. An ignorance of this fact is pardonable in non-medical men. They 
may talk of vessels being ruptured or " uncapped, in bleeding from the 
lungs; but for one who professes to be a physician to talk thus betokens a 
ridiculous and unpardonable ignorance. But this, perhaps, is to be expected 
of a sect that discard pathology as being useless. 

Kupture does often occur in the brain, and Dr. Wells treats us to a some- 
what remarkable supposition in regard to hemorrhage in that organ. He 
says, that "the hemorrhage might have come from rupture of the longitudinal 
sinuSj and coming through the ethmoid plate , and it is only conjecture that it 
came from the lungsP His idea is, that the sinus having been ruptured, the 
blood came through the little openings in the cribriform plate of this bone 
into the nose, just as water or any fluid would run through a sieve. This 
was probably a clear idea to the jury, though it be an idea of an impossi- 
bility, or rather of a series of impossibilities. 

Let us see how much this pathological supposition of the learned and inge- 
nious Dr. Wells implies. First, there must be a rupture of the longitudinal 
sinus. This can only result from two causes, mechanical violence and ulcera- 
tion. As to the first, nothing short of a breaking in of the skull could do it; 
the pressure of blood induced by convulsions never could. As to ulceration 
of the sinus, if it ever do occur, it must be exceedingly rare. And if it 
should occur, the blood would be diffused in every direction over the surface 
of the brain, unless indeed the march of the ulceration should be towards the 
ethmoid bone. And then, in order to have the blood discharge from the 
nose, there must be actual ulceration of the bone itself, and of the membrane 
in the nose that covers it. 

Dr. Wells evidently contemplates no such series of events as this in his 
supposition, for he says: ''I see no difficulty of a certain amount of pressure 
forcing the blood through the openings in that bone." He forgets, if he ever 
knew, that these openings are wholly closed by the branches of the olfactory 
nerves and their accompaniments, and are covered tightly by the membrane 
lining the nasal cavities; so that no blood can come through them till all 
these soft parts be removed, for the same reason precisely that a fluid cannot 
be poured from a bottle till the cork be drawn. 

Dr. Wells heaps blunder upon blunder. He states that softening of the 
brain" is necessary for this discharge of blood through the ethmoid plate. 
How this can have any connection with such a result we leave it to homoeo- 
pathic pathology to show. One might as well talk of blood being discharged 
from the lungs through the skin that covers the chest, and of a softening of 
the lungs as being necessary to its discharge in this way. Well does Dr. 
Gilman remark: "I cannot conceive of the hemorrhage coming from the brain 
in the manner spoken of any more than I can conceive its coming from the 



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brain to tlie ends of the fingers." These homoeopaths are familiar with con- 
ceptions of impossibilities. They are to be found here and there in their 
standard works. Jahr states in his Ilanual, for example, as one of the effects 
of stramonium, that "air passes out of the ears.'' How this can be, unless 
when the drum of the ear is deficient or absent, we of course cannot under- 
stand, but we suppose it is plain enough to one who can conceive of blood 
being forced through the ethmoid bone. 

But it would seem that Dr. Wells had, on reflection, some idea of the ab- 
surdity of his supposition, for in testifying afterward, on being recalled, he 
says of it: "This was not intended to explain the hemorrhage in this case, 
but only as a possible occurrence. My opinion now is that the hemorrhage 
comes from the lungs," an opinion in direct opposition to that which he gave 
when he testified first, for he then laid great stress upon his idea of a flow of 
- the blood through the ethmoid bone, and said that " it is only conjecture that 
it came from the lungs." The homoeopathic reporter, it seems, had so lively 
an idea of the ridiculousness of Dr. Wells' supposition, that not the most dis- 
tant allusion to it is given in his report of the doctor's testimony. 

Though Dr. Wells was so ready with his supposition in regard to the 
hemorrhage, he seems unaccountably reluctant to explain another phenomenon 
in the case, the appearance of bloody serum in the chest. He says on this 
point : — 

"I decline accounting for the appearance of this bloody serum in the chest, 
on account of the uncertainty which attends its origin. Whether it took place 
before death or after, the origin of the serum is all uncertain. I have made 
post-mortem examinations of persons who have died from diseases of the lungs, 
and have found serum in the cavity of the chest. I have seen it of all amounts, 
from as much as the chest was capable of holding down to a very little. Some 
died of pleurisy, some of phthisis. I have opened persons who have died of 
other diseases, such as dropsy of the brain, jaundice, with considerable serum 
in both pleural cavities, and no disease of lungs or pleura. I am not aware 
, that I ever saw bloody serum in any case that I remember.'' 

Now what mystery there can be about the " origin" of this bloody serum 
we cannot see. Where else could it come from but the pleura? It being a 
close sac, there is no way for the blood to get into it but by exhalation with 
the serum from this membrane. The membrane itself and the lungs which 
it covered were highly congested, as appeared from the post-mortem exami- 
nation, and with this congestion there is no mystery about the origin of the 
bloody serum. The merest tyro in medicine would be at no loss on this 
point. And yet the erudite Dr. Wells, who could suppose a hemorrhage 
through the cribriform plate, all at once becomes cautious, and declines 
accounting for a phenomenon, the cause of which is palpable. We do not 
wonder that he prefaced such a declinature with the remark, that "post- 
mortem examinations are of much less value than is commonly supposed." 
He certainly had not profited much by them. 

We come now to look at the testimony about the mumps, which the 
homoeopathic doctors all considered as the undoubted cause of the death, in 
the case. Dr. Wells remarks thus on this point: — 

"The reason why I supposed she had mumps, and they were translated to 
the membranes of the brain, is because, 1st, for the two or three weeks pre- 
ceding her death she had no brain symptoms whatever, not even a pain in her 
head, and I questioned her every day on that point; 2d, the attack came on 
just at the time mumps will come if she had taken it from her mother; 3d, the 
slight stiffness and tenderness of the neck, as mentioned; 4th, the character 
of the convulsions; 5th, the termination by hemorrhage. The hemorrhage 
might have come from rupture of the longitudinal sinus, and comdng through the 
ethmoid ylate; and it is only conjecture that it came from the lungs." 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



115 



Of course, if the hemorrhage came from the lungs, as he afterwards said 
was his opinion, he would dismiss his fifth reason. The force of the other 
four reasons which he gives so systematically, will appear to the reader as we 
proceed. 

The translation of mumps to the brain, which the physicians who testified 
deemed to be very rare, none of them ever having seen it, the quacks talked 
about as if it were a common thing. Dr. Dunham said he had seen a case 
which terminated just as the case of Agnes Lottimer did, by hemorrhage 
from the nose and mouth. Dr. Hull had a remarkable case of metastasis of 
this disease in his own family, which he relates in his testimony. He says : 
" In the case of a child in my own family, the muuips apparently commenced 
in the bowels, and the application of a poultice of angle-icorms to the parotid 
gland caused a metastasis of the disease from the bowels to the parotid. The 
brain was somewhat affected, but not a complete metastasis. The child re- 
covered." We suppose that the metastasis to the brain would have been 
complete if the angle-worm poultice had not drawn the mumps right to the 
parotid gland when it left the bowels. How the poultice acted in consonance 
with the great Hahnemannic law of cure, we are at a loss to understand. 
The explanation of this could probably be achieved only by one who knows 
how blood can get through the cribriform plate. 

Though the homoeopathists all agreed that the mumps killed the patient, 
we fail to see, and the physicians who testified failed to see, that there was 
any evidence of the existence of mumps in the case. It was supposed that 
the patient took the mumps from its mother. But the description which the 
mother gave of her own case is certainly not a description of mumps, but of 
common inflammation of the jaw, or ague in the face, as it is commonly 
called. It is as follows : — 

"On the 14th of September, about 11 o'clock at night, I sent for Dr. Dun- 
ham, with my tooth paining; it seemed to have a great deal of inflammation; 
I had leeched the gum in the afternoon, and had applied hops and vinegar to 
my face about eight o'clock in the evening; my gum and the side of my cheek 
were very much swollen. It pained me all underneath my jaw-bone, more the 
jaw-bone than the glands; the swelling was more under the jaw-bone; the 
glands underneath the ear seemed slightly, but not much, swollen. It was a 
day or two before my child died that I got entirely free from all pain and sore- 
ness about my face and neck; I never got entirely well of the swelling and 
pain in my face, and then the swelling commenced under the ear; it was all 
together. My sister, Mrs. Large, told me that, when a child, I had mumps on 
one side. My sister could not recollect, and I do not know, on which side of 
my neck I had mumps. About the third day after I complained of this tooth, 
Dr. Wells told me I had mumps. The next morning Dr. Wells prescribed for 
my face, and attended me for it constantly. My face was still swelled, and 
Dr. Wells told me there was matter on the tooth; at the time he told me I had 
mumps. I am certain this was all together, and not two different attacks. I 
have frequently before had trouble about my teeth and gums, with swelled face 
frequently; at the times before, my jaws have been stifi" and a great deal of 
swelling of the face, though not so much as this time. I have before had to 
call in medical advice ; Dr. Wells several times attended me with it.'' 

From this account it appears that the first sign of trouble was in or about 
a tooth. Dr. Hull, we suppose, would say that in this case the mumps began 
in the tooth, just as in the case of his child it began in the bowels. Perhaps 
the reason that it did not get more fully into the parotid gland was, that the 
true homoeopathic remedy, an angle-worm poultice, was not applied. It was 
not till the third day of her sufl'ering that Dr. Wells told Mrs. Lottimer that 
she had mumps. Matter was soon found, as he told her, and yet he still said 



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the case was mumps. This positive opinion thus given, certainly indicates a 
blundering looseness in opinionating. The utmost that could be claimed in 
endeavouring to make out a case of mumps would be, that possibly this dis- 
ease might be present at the same time with the inflammation of the jaw. 
And the fact that she had once had the mumps is fatal to this supposition. 

The evidence that the child had the mumps is even less than that the 
mother had it. Dr. Wells' testimony about this is as follows: ''The third 
day before her death, she complained that she did not feel as well ; complain- 
ing of nothing specific, however, except a slight stiffness of one side of the 
neck, with slight tenderness on pressure over the upper and anterior part or 
edge of the cleido-mastoid muscle. The domestic attendants thought she was 
getting mumps, as her mother had mumps about one week before. There 
was no swelling of the parotid gland." I will simply quote in regard to this 
a remark of Dr. Grilman's in his testimony : " Here are mumps spoken of 
without any swelling or tenderness of the parotid gland. Now 1 take it, this 
is like speaking of smallpox without any eruption.'' 

But it was this strange concealed kind of mumps that went to the brain 
and destroyed life ! And what is most wonderful of all is, that the disease 
appeared one day in the shape of pain and soreness of the neck, the next day 
disappeared altogether, and on the third reappeared in the brain ! For the 
order of events and of the doctor's opinionating is this, as appears from Mrs. 
Lottimer's testimony. She says: — 

*'0n the Thursday previous to her death, Agnes first complained of pain and 
soreness in the neck, and on that day I called Dr. Wells' attention to it; he did 
not examine her neck on Thursday ; I did two or three times ; he did not ac- 
count for the stiffness, &c. On Friday I next called his attention to it; he then 
examined the neck ; he said there was no appearance of mumps now at alL 
On Saturday, about 12 o'clock, Agnes was taken with convulsions. The time 
Agnes was in a convulsion, he said he thought that the mumps had flown to 
the brain.'^ 

Where the mumps were on Friday, when the doctor said there was now no 
appearance of mumps, we are not told. The author of the ingenious suppo- 
sition of hemorrhage through the ethmoid bone probably supposed that the 
mumps were secretly hatching a disease which appeared in convulsions the 
next day. 

The verdict of the jury in this case was of a non-committal character. In 
regard to this the following remarks are made in the preface to the report of 
the testimony : — 

" With their 'finding' we have no concern. The public health demanded of 
the coroner the investigation, and for the fearless performance of his duty he 
deserves the thanks of the community. Homoeopathic physicians of the vicinity 
have chosen to stigmatize the proceedings as persecution. If we are to believe 
them and their advocates, this inquest was something strange, and till now un- 
heard of. The patient, say they, was attended by a physician, and he pre- 
scribed 'according to his system; surely, he is not to be held accountable.' 
How has it been in similar cases? It is not very many years ago that a young 
man named French was attended by a Dr. Frost, who 'prescribed for liim ac- 
cording to his system.' French died, and not only did the coroner hold an 
inquest, but the grand jury found a bill; Frost was tried, and, we believe, con- 
victed of manslaughter! As in the case of Wells, physicians (so called) from 
all quarters gave their testimony that the treatment had been judicious 'ac- 
cording to their system.^ Yet Frost was convicted. To be sure, Frost's sys- 
tem was Thompsonianism ; but is that worse than homoeopathy ? In the one 
system we have Thompson, Lobelia, and Number 7 ; in the other, Hahnemann, 
Belladonna, and the Thirtieth Dilution. AVho shall decide between the Dutch 



1855.] 



Inquest on the Death of Agnes E. Lottimer. 



117 



and the Yankee quack? "Who will venture tanias componere lites? One credit 
we will allow these Homceopathists ; if their knowledge of anatomy is as infi- 
nitesimal as their doses, their esprit de coyys is as high as their dilutions. 
During the trial they made common cause — high dilutionists and low dilution- 
ists united to assure the jury that the treatment was 'judicious;' though it will 
be seen that they by no means agree that they would have treated it in the 
same way." 

We felt some reluctance to notice the pamphlet before us on account of the 
feelings of the family and the friends of the patient. The loss to parents of 
a loved child is an affliction sufficiently hard to be borne, without having added 
to it the reflection, that their child was a victim of outrageous quackery in the 
shape of a vaunted system. We would like to relieve their hearts from such 
a festering wound as this reflection must create. It gives us pain to open this 
wound afresh; but duty has required of us, as public journalists, the expo- 
sure we have made of the gross quackery that produced the fatal result in 
this case. The exposure is painful to the afflicted family, but it may save by 
its warning many other families from experiencing a similar affliction. 

Before dismissing this case, we have a few remarks to make upon some of 
the mental and moral developments of homoeopathy, brought out in the tes- 
timony. 

There is a striking contrast to be observed between the character of the 
testimony of the physicians in this case, and that of the testimony of the 
homoeopathic quacks. The testimony of the former is straightforward, clear, 
common sense testimony, without any useless or irrelevant matter; while that 
of the quacks is confused, inconsistent, full of assumptions and blunders, and 
cumbered with a false display of learning and of minute observation in regard to 
the effects of remedies. The physicians who testified are evidently men that 
are accustomed to definite thinking and to accurate examination of evidence. 
The quacks who testified, are, on the other hand, men who are accustomed to 
talk loosely and think loosely, although they make large pretensions to great 
exactness in their observations of disease, and of the effects of remedies. 

It is this loose habit of thinking which appears as a very prominent charac- 
teristic of the practitioners of homoeopathy. That this is a legitimate result 
of their system, any one can see who will take the trouble to look into any of 
their standard works, especially the larger ones, like Jahr's Manual, for ex- 
ample. The descriptions given of the effects of remedies are the most random 
and confused collections of everything that can be conjured up by the most 
exuberant fancy, as the reader may see from the extract from Jahi-'s 31amialj 
given in another part of this article. There are over four hundred closely 
printed pages of such discrepant nonsense in this book ; and this is but one 
among many such books. Those who conjured up these collections must 
have resigned all definiteness of thought, and those who take them as autho- 
rity must do the same. 

Adherence to any exclusive system has a tendency to obscure as well as to 
narrow the mind. It does so because the mind acquires the habit of slurring 
over all facts that are inconsistent with its favourite system. This is espe- 
cially true of homoeopathy, not only because it is an exceedingly exclusive 
system, having but one law of cure ; but also, because it has gathered such 
a mass of loose and bewildering details, mixtures of entities and nonentities, 
chiefly the latter. 

There is, from these causes, a manifest lack of straightforward honesty of 
mind in homoeopathists as a class. They are habitually familiar with plausi- 
bilities and glosses and misrepresentations ; and the transition from this to 



118 



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wilful misrepresentation is, to most men, an easy one. Even one who goes 
into homoeopathy, from strictly honest conviction of its truth (which we be- 
lieve to be exceedingly rare), experiences this corrupting influence upon his 
mind and heart. He is subjected to the temptation to be dishonest continu- 
ally. No homoeopathic doctor can get along with his patients and the public 
without making constant misrepresentations. He acquires a loose habit in this 
respect necessarily. A giving up of the habit would involve a giving up of 
homoeopathy. No homoeopathist can, in the strictest sense of the word, be 
honest. Many of them are dishonest in the full sense of the word. They 
are wilful deceivers. Our experience would lead us to say that this is true of 
the great majority of them. 

We have already alluded, in the first part of this article, to a dishonest 
expedient very commonly resorted to by homoeopathists. We refer to their 
attributing death to some other disease than the one which the patient had 
in the beginning. This is occasionally the true view of the cause of death ] 
and, because this is so occasionally, they take the liberty of considering it as 
a common occurrence, for the purpose of deceiving the public in regard to the 
results of their practice. For example, if an epidemic be prevalent, although 
the homoeopathists may be abundantly unsuccessful, they commonly make 
out a good story of their success, to be retailed about by their friends, by 
resorting to the expedient mentioned. We knew a homoeopathic doctor to 
claim that he had lost no cases of dysentery when it was epidemic, although 
it was well known that he had lost many. How did he make out his case ? 
Why, this one died of typhoid fever that " set in/' that of hemorrhage from 
the bowels, and so on. He even went so far as to insert these as causes of 
death in his certificates for the registrar. He pursued a course of wilful and 
bold falsehood. And yet this man has a good standing in the community, 
and he had a prominent clergyman among the believers and busy retailers of 
his falsehoods. 

One of the most common practices among homoeopathists is to cheat their 
patients with the idea that they are under homoeopathic treatment, when they 
are in realit37- taking the full doses of " the old practice.'^ If nature will cure 
while the show of medicine is kept up with the high dilutions, it is very well. 
The cure, to be sure, is sometimes slow, but the patient is quieted w^ith the 
idea that the mysteriously powerful pellets are gradually eradicating the dis- 
ease, and then the slowness of the case insures a good long bill. But, if this 
course does not succeed, the high dilutions are forsaken, and full doses are 
given, after the manner of the "allopaths.'' This is done, when it can be, in 
secrecy ; in other words, downright cheating is practised upon the patient. 
And when, from the bitterness of the medicine, or some other cause, this 
secrecy cannot be practised, there is nothing said, unless the patient notices 
the change. If he does, the common excuse is, that the great law of cure 
applies to all sorts of doses, which is as ridiculous as it would be to say that a 
large spike would do the same thing as the finest needle, and in the same 
manner. Indeed, this comparison fails to come up to the ridiculousness of 
the position of these homoeopathists, for the dilFerence between a high dilution 
and a common dose of "the old practice" is vastly greater than that between 
the spike and the needle ] it is greater even than the difi'erence between an 
atom and a world. Surely, if both infinitesimal and common doses cure, 
they do so clearly in difi'erent ways, and not by one and the same law of cure. 

So common has this administration of ordinary doses become among homoeo- 
pathists, that it has come to be the prevalent doctrine of this sect of quacks, 
that Hahnemann's law of cure applies equally to doses of all sizes. It is true, 



1855.] 



Inquest on the Death of Aynes E. Lottimer. 



119 



that some of them resist this as an unholy mixture ; but the practice is all the 
while gaining groundj and homoeopathy, like every other form of cjuackery 
before it, is fast losing its distinctive characteristics, and will ere long be 
merged in something else, as new novelties arise in the cjuackish world. 

Among the remedies most commonly used in ordinary doses by homoeo- 
pathists is Cjuinine for the cure of intermittent fever. Drs. Hull and G-ray 
testified in this case that they used it thus. The truth is, that the proof of 
the efficacy of C|uinine in ordinary doses in this disease is so well established, 
that homoeopathists are obliged to use it thus in spite of its being inconsistent 
with their system. If they refuse to use it, they are in danger of meeting 
with such disagreeable circumstances as have fallen to the lot of Dr. Wells. 
The losing of two cases of intermittent fever in one family, and the storm of 
public reprobation which has fallen upon him in consequence, we think, must 
cure him of adhering to infinitesimals, unless all this may filter through his 
mind and conscience as easily as he fancies blood to go through that cribri- 
form plate. 

The looseness of ideas, of which we have spoken as being even more cha- 
racteristic of homoeopathic quacks, than of quacks of any other class, is exhi- 
bited in this case more by Dr. Wells than the other homoeopathists, because 
his testimony is more full than theirs. It is evident that he has been so much 
in the habit of talking in a random and confused manner among his patients, 
that this habit clung to him when testifying under the solemnities of an oath. 
Confused ideas of symptoms and of remedies, groundless assumptions, and 
palpable blunders, appear throughout his testimony. His loose habit of 
thinking was plainly the cause of his blunder about the hemorrhage. A 
moment's honest, sober reflection would have showed him the ridiculousness 
of his supposition and the impossibilities that it involved. But the power of 
sober, honest reflection he had destroyed by the long cultivation of his loose 
habit of thinking and talking, and so he plunged into this blunder, as he had 
into many a blunder before it. The same can be said about his testimony in 
regard to the mumps, showing an utter want of discrimination ; and so of 
other points in this remarkable testimony. 

Tried by the common principles by which men try the character of testi- 
mony on all other subjects, this testimony of Dr. "Wells is wholly unreliable. 
We can feel no certainty at any time that he is making correct statements. 
What he says may be true, or may not be true. There is no confidence to 
be put in a mind that is so befogged. He is not to be credited, for the same 
reason that any one would not be credited that should talk as loosely and non- 
sensically on any other subject. Suppose any question of practical science were 
involved in a legal investigation before a jury ; for example, some question 
in regard to the explosion of steam-engines. If any one should talk as much 
at random and blunder as egregiously on this subject as Dr. Wells did in 
regard to anatomy, pathology, and the effects of medicines, his testimony 
would not be considered as having the weight of a feather. If he should say, 
for example, that steam could come through the pores of a boiler in great 
quantities, and that, therefore, a rent of the boiler was not at all necessary to 
the explosion ; he would be no farther out of the way than Dr. Wells was in 
saying that blood could come through the openings in the ethmoid bone. 
And if he should say that he declined accounting for the moving of the piston 
of the engine, he would not show greater ignorance than Dr. Wells did when 
he said, " I decline accounting for the appearance of this bloody serum in the 
chest, on account of the uncertainty which attends its origin.^'' To such a 
witness neither judge nor jury would give any credit. But nonsense in 



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medicine seems to meet with special tolerance. In the case before us, it 
would appear by the non-committal character of the verdict, that the jury 
gave nearly as much weight to the testimony of Dr. Wells, although he made 
a fool of himself, and to that of his brother quacks, as to the clear and sensi- 
ble and conclusive testimony of the eminent physicians who testified in the 
case. 

It is time that men of standing and influence in the community should 
apply the same rules of judging to medicine that they do to other subjects, and 
should cease to consider sensible and rational physicians as upon a level with 
the irrational practitioners of a system of quackery. Folly in the science or 
the practice of medicine is just as bad as it is in any other science or practice, 
and should be treated with the same contempt; but it is not, commonly, 
thus treated. A large portion of even the men of standing in the community 
tolerate, in medicine, folly which they would abominate in anything else. 
Many clergymen, we regret to say, do not treat the medical profession in this 
respect as they would wish to be treated themselves. Mormonism is to 
theology, both in its falseness and its folly, what homoeopathy is to rational 
medicine ; and yet a clergyman began a long notice of a book that exposed the 
fallacies of homoeopathy by saying, who shall decide when doctors disagree ? 
If this clergyman should write a book, exposing the follies of Mormonism, it 
would be quite as proper for us to begin a notice of it with the taunt, who 
shall decide when divines disagree? Little do clergymen and others think 
how galling it is to an honorable and rational physician, to be put in the same 
category with men that utter such blundering nonsense, as appears in the 
testimony of the homoeopaths in the pamphlet before us. 

We have thus commented on the testimony in this case, not for the purpose 
of convincing our readers of the falseness and folly of homoeopathy ; this 
would be unnecessary, for they have long ago seen enough of this system of 
quackery to know what it is. We have made our comments for a different 
purpose. We wish to supply our readers with the means of convincing non- 
medical men, as they have opportunity from time to time, that homoeopathy 
is unworthy of their belief and confidence. The facts developed in this article, 
and in our review of Simpson's Facts and Tendencies of Homonopatliy ^ in the 
J anuary number of last year of this J ournal, furnish considerable material 
for this purpose. Physicians have a duty to perform to the community in the 
exposure of quackery, which we pointed out at some length in our review of 
Simpson. We will, therefore, refer our readers to the views there expressed, 
instead of again dwelling on the subject here. W. H. 



1855.] 



121 



BIBLIOGRAPHICAL NOTICES. 

Art. XV. — Transactions of American Medical Societies: — 

1. Transactions of the Ninth Annual Meeting of the Ohio State Medical Society, 
held in the City of Cincinnati^ June 6th, 1854, 8vo. p. 172. 

2. I'he Proceedings and Reports of the Medical and Chirurgical Faculty of Mary- 
land, Incorporated in 1799, at its Annual Session, in June, and Special Session 
in September, 1854, in the City of Baltimore, 8vo. p. 82. 

3. The Transactions of the New York Academy of Medicine. Yol. I. Part II. 
Containing Hospital Hygiene, Illustrated, by John H. Griscom, M. I). 8vo. 
VV- 12. 

The Transactions of the New Yorlc Academy of Medicine. Vol. I. Part III. Con' 
. taining A Report on Solidified Milk, by the Standing Committee on Public 
Health and Legal Medicine. 8vo. pp. 12. 

1. The volume of Transactions of the Ohio State Medical Society at its ses- 
sion of 1854, comprises a number of reports and papers of a highly interesting 
character. One of them, the Prize Essay of Dr. M. B. Wright, of Cincinnati, on 
Difficult Labours and their Treatment, we have considered vrorthy of a special 
notice, and one more extended than it will be convenient for us to bestow upon 
the other portions of the Transactions— vjq have accordingly assigned it a sepa- 
rate place in our Bibliographs. 

The valedictory address of Julius S. Taylor, M. D., after retiring from the 
chair, as President of the session of 1854, though of a somewhat discursive 
character, is replete with correct and noble sentiments. Its leading topic is 
the necessity of union of action, and perfect organization among physicians 
for the promotion of the character, interests, standing, and usefulness of the 
profession — the cultivation and advancement of medical science and literature, 
and the elevation of the standard of professional education. This topic is urged 
with an earnestness and zeal becoming its importance. 

The Ohio State Medical Society, Dr. Taylor informs us, was organized in the 
year 1846, by the association of twenty-five physicians. 

" From that date," he remarks, " the labours of its members have been de- 
voted and zealous, and their efforts have been crowned with the happiest 
results, in the production of many reports and papers relating to our science, 
which are of great importance to the profession generally. 

" Since its organization, numerous truly educated physicians have become 
members, so that at our last annual meeting we found enrolled three hundred 
and nineteen. This, however, is but a fraction of the many truly and correctly 
educated physicians of the State of Ohio. Some may, perhaps, object to be- 
coming members of this Society from the fact, that the results of our labours 
are yet so small. We would say unto such, ' Come in and assist us, as the har- 
vest is yet large and the labourers few.' 

" The results that will follow this organization, if it shall continue to increase 
in numbers until it has enrolled among its members the nam» of every phy- 
sician within the State, that has the true Science of Medicine at heart, and who 
will be willing to lend his individual aid to the promotion of a general science 
of Medicine, will soon be found to present an interest so great, to create an 
emulating influence so profound, an education so perfect, a friendly intercourse 
so extended, a professional harmony so complete, and so general a desire to aid 
each other in all that shall tend in the least to advance our cause — the cause 
of legitimate medicine — that the most skeptical mind will soon be obliged to 
acknowledge that our cause is just and our objects attainable. 

" To accomplish a result so desirable — will require, certainly, a continued 



122 



Bibliographical Notices. 



[July 



labour; a correct deportment in all professional etiquette; a fixed determina- 
tion in every member to look to the interest of all as to that of his own. These, 
however, are but small requirements, and I have no doubt but they can and 
will be lived up to by all of us with cheerfulness and fidelity. If such shall be 
the case, as a Society, we have nothing to fear ; our cause will be carried on- 
ward and upward, until it shall be crowned with the most perfect triumph.'^ 

The importance and necessity of organization among all the members of the 
medical profession, in district, county, and State societies; and the concentra- 
tion of these local organizations, by a justly apportioned and properly ap- 
pointed delegation in the National Association — having the same great objects 
in view as are set forth in the constitution of the State Medical Society of Ohio ; 
mutual recognition and fellowship, the maintenance of union, harmony, and 
good government among its members, the cultivation and advancement of me- 
dical science, and the elevation of the standard of medical education — cannot 
be too frequently, nor too earnestly urged upon physicians. They who stand 
aloof from these organizations, or view them with a distrustful and jealous eye, 
if they have no sinister ends to answer by keeping themselves apart from their 
brethren, no selfish purposes to be accomplished that would not comport with 
the requirements of the code of ethics of the profession — if their desire is to 
base their success only on their characters as educated, intelligent, and honour- 
able practitioners of the healing art, do a wrong to themselves as well as to the 
entire body of the profession of which they claim to be legitimate members, by 
refusing to identify themselves with "the common-weal,'' and lending their 
personal aid and influence towards its maintenance and promotion. With the 
elevation and aggrandizement of the entire profession must necessarily be con- 
nected the promotion of their individual influence and interests. 

A report is presented by the Committee on Medical Ethics through its 
chairman. Dr. John Dawson. This is a pertinent, and well drawn up report. 
The committee, as its name imports, has imposed upon it the duty of making 
known to the society the moral standing of the profession throughout the State. 
This delicate task the committee have performed with a good deal of tact. By 
confining themselves, for the most part, to generalities, they have avoided 
ofi"ence to individuals, while by the judicious remarks and suggestions they 
have thrown out as to the mo^ prominent derelictions of the code of ethics of 
which the physicians of Ohio have been guilty, and the evils to the profession 
thence resulting, they will have efi'ected more good, probably, than if they had 
made more specific charges and brought them home in direct terms to indi- 
viduals. 

After quoting the 1st section of Article I., of the second chapter of the Code 
of Ethics, Dr. Dawson very pertinently remarks: — 

"A doctrine very clearly set forth in this section, is, that the Profession of 
Medicine has a character, which is the property, not of a single member, or of 
the members of any particular region, but of the Faculty of the whole country. 
This character is the result of the labours of the upright in heart and the self- 
sacrificing for centuries ; and as a consequence, it is no wonder that there are 
many to be found who venerate it, and exert their best abilities to maintain its 
dignity and honour. 

" The introduction of an individual into the Medical Profession consists in 
nothing more nor less than the clothing of him with the character of the pro- 
fession, and in imparting to him the right to exercise everything pertaining to 
it, for the good of society and of himself. The possession of such a treasure, 
together with the rights pertaining to it, must necessarily imply on the part of 
the individual thus invested, certain obligations, for without the existence of 
these, the relation would be imperfect. These obligations, among other things, 
require of him that he shall exert himself in every reasonable manner, and on 
all proper occasions to maintain the portion of professional reputation intrusted 
to his care ; and that he shall also add to the common stock. For, it has been 
in this way, and in this way alone, that our common character has been built 
up — has been formed." 

Among the derelictions of the Code of Ethics by certain of the physicians of 
Ohio, noticed in the report before us, is that of " speaking evil of each other." 



1855.] Transactions of the Ohio State Medical Society. 123 



Our conversation," says Dr. Dawson, " about each other, when surrounded 
by the circumstances of rivalry in practice or in teaching, too often wants 
candour, liberality, and dignity. Old men are denied the veneration and 
respect due to their years and services ; younger ones, who happen to be pro- 
minent, are criticized, persecuted, and occasionally slandered.'" 

Another violation of ethics referred to in the report, is the mean attempt on 
the part of physicians, when called into consultation with younger and less 
prominent members of the profession, to weaken confidence in the medical 
knowledge and skill of the attending physician, with the view of attracting to 
themselves the future patronage of the family and friends of the patient. 

*' Impressed," says Dr. Dawson, " with the belief that the value of consulta- 
tions most frequently consists in inspiring confidence in the physician having 
charge of the case, and assisting him as one mariner would another that had 
been tossed about by contrary winds, to keep his latitude and longitude right, 
until securely anchored in the port of safety, we cannot avoid suggesting the 
propriety of a review and revision of the whole subject. Consultations cannot 
be dispensed with without incalculable detriment to the sick, saying nothing 
about their value, when honourably conducted, to the profession. But we re- 
peat, that it is the testimony of physicians all over the State, that they are 
diminishing in frequency ; that many of the older physicians are avoiding them 
as useless, while the younger ones, are complaining that they seldom ever get 
through with them without being injured. To us, the existence of such facts 
is everything else than agreeable, and of course our only object in alluding to 
them, is, that our Society may look them in the face, and make an effort at 
their correction." 

It is but proper to state that while the Committee on Ethics have considered 
it their duty to point out the existence of such deviations from the path of pro- 
fessional rectitude as have been just referred to, they bear cheerful testimony 
to the honourable character and conduct of *'the great mass of the quiet and 
working portion" of the physicians of Ohio. 

" In looking over our State," they remark, " and taking an imperfect survey 
of our physicians, and the manner in which they are demeaning themselves to 
the profession and to the people, we see much to excite admiration and grati- 
tude. Labouring for less pecuniary reward, and at greater sacrifices of leisure 
and all the conveniences and comforts of life, than what in these times pertains 
to any other kind of business, they seem, nevertheless, as a general rule, to be 
conducting themselves very creditably, so far as an honest and faithful observ- 
ance of the essential rules of ethics are concerned, while, at the same time, 
they are performing their duties to the people, frequently under circumstances 
of danger, with alacrity." 

As a subject following within the range of ethics, and certainly of no slight 
importance, the committee notice the insufficient compensation too generally 
acceded to the physician for his professional services. 

" To some extent," they observe, "this has always been the case, but at the 
present, it is eminently so. Every department of labour or service has exacted 
from the community increased rates of remuneration, while the services of the 
physician, his deprivations and sacrifices, have experienced, so far as increase 
of compensation is concerned, no change. Indeed, we are not sure but that 
the reverse is true. Physician's bills, from all that we can learn, are now paid 
off with less money, and more reluctance than they were a quarter of a century 
since. Many of our best educated young physicians find out, on entering the 
profession, that the compensation for their services, even if they succeed to a 
reasonable amount of business, is less than w^hat can be obtained in many of 
the ordinary pursuits of life, and, as a consequence, they abandon the profes- 
sion. Many, too, who have laboured in the ranks of the profession for years, 
find out at last that they are failing to secure the means necessary to sustain 
the infirmities of life, and in disgust turn their attention to other pursuits." 

The small pecuniary return which physicians generally receive for the ser- 
vices they render — the impossibility, excepting under circumstances of rare 
occurrence, to lay by from the legitimate income of the profession any provi- 
sion for the declining years of life, have induced more than one, who might 



124 



Bibliographical Notices. 



[July 



otherwise never have been tempted to do wrong, to resort to sinister and un- 
worthy means of increasing their practice and augmenting their fees ; or even 
boldly to break faith with their brethren by entering openly the regular ranks 
of empiricism and imposture. 

If the public would secure for their service a well educated and experienced 
body of medical practitioners, upon whom they can depend, with full confidence, 
when disease assails them and their lives are endangered, they must be pre- 
pared to afford a compensation more in proportion to the value of the services 
they require of the physician ; one better calculated to place him beyond the 
fear of want, and to relieve his mind from the harassing cares thence engen- 
dered, than they are now willing to do. 

Have the profession within their reach any means to raise their compensa- 
tion to a more equitable footing ? 

*' Heretofore, says Dr. Dawson, reliance has been placed upon the getting 
up of fee bills. Badly these have worked in most places where they have 
been tried. Too frequently the people have looked upon them as combinations 
to extort exorbitant charges, and while it is humiliating to acknowledge it, it 
is a fact that, too often, they have had their prejudices strengthened by the 
testimony of some unworthy member of the profession, one such being, un- 
fortunately, to be found in almost every neighbourhood, who, by uniting in the 
clamour, is in hopes of obtaining popular favour and increased patronage. In 
view of this state of things, and of the propriety of doing something, no mea- 
sure seems to us more likely to be attended with good results than a general 
movement on the part of the older physicians, those well established in the 
confidence of the community. Let them, by concert of action, take the proper 
ground in relation to the matter and maintain it, and the work is done. "What 
they do is generally regarded as right, should it even interfere with the usages 
of the purse. They owe it to themselves, and to the profession to lead off in a 
measure so necessary at the present time, and one that unless carried out will 
require that our profession shall frequently be united with some other occupa- 
tion in order that the means of a reasonable support shall be secured." 

In the conclusion of their report, the committee briefly animadvert on the 
general standing of the profession, at the present moment, in the estimation of 
the public. 

Like many of the things to which they previously allude, the public estimate 
of the medical profession is, they confess, not what most of us desire. 

The cunning subterfuge, the impudent pretension, the total disregard to 
truth, the mean truckling to public prejudice and to popular errors which dis- 
tinguish the bold and industrious opposition to scientific medicine of the vast 
host that muster in the ranks of the irregulars, whose only aim is gain, has 
had the effect of destroying, to a very great extent, the confidence in it and its 
legitimate practitioners, of large portions of different communities. 

" It were well," remark the committee, " if this injurious influence was ex- 
erted only by the unwary and ignorant. Then we could look forward with 
some hope to the changes which the schoolmaster is making upon the race, as 
the era of deliverance from the trouble and annoyance. But how frequent and 
how common is it to see those communities, that we have been wont to regard 
as the most intelligent, taking the foremost rank in the patronage of the most 
transparent humbugs of the day. And, what is still worse, many of our dis- 
tinguished men, those intrusted with the care of church or of State, and who 
enjoy a large portion of public confidence, not only seem an easy prey to the 
mountebank, but, when occasion requires it, are ready to aid, by their personal 
or official influence, in almost anything that shall detract from the character 
and claims of legitimate medicine, scientifically studied and scientifically 
practised. 

"Besides the operation of causes external, we have those of an internal cha- 
racter, the influences of which are decidedly more fatal. To some of these we 
have already alluded in another connection, and only notice them here to in- 
crease attention to them, as our worst enemy. It is an old maxim that teaches 
the doctrine, that if we would have others respect us, we must respect our- 
selves. We have seen enough to convince us all, that, although pur existence 



1855.] Transactions of the Ohio State Medical Society. 125 



as a faculty is indispensable to the welfare of humanity, still we cannot rely 
on the claim of utility alone, as the means of securing confidence, and of giving 
us popularity. To amenity of manners, and straightforward, upright conduct ; 
to a disposition to treat each other, under all the circumstances of rivalry, as 
gentlemen, as brethren; to the habit, in all our connections, of avoiding con- 
tumelious or sarcastic remarks in relation to each other; to union among our- 
selves, and to industry in cultivating every department of nature and art 
available in the management of physical suffering and infirmity, we may look 
with confidence as being the only means of placing us in a position to command 
the respect and influence to which we are so justly entitled." 

The prize essay of Dr. Wright on DiflB.cult Labours, which follows the report 
on medical ethics we shall notice in another place, in the present number of 
our Journal. 

The paper next in order is by Dr. L. M. Lawson, formerly of Cincinnati. Its 
subject is Practical Observations on the Diagnosis of Phthisis Pulmonalis. 

The author presents a very fair, succinct view of the subject, which may be 
read with profit, especially by the younger members of the profession. In its 
more advanced stages, tuberculosis of the lungs presents no difiiculty in its 
diagnosis to the well-instructed practitioner. In the very commencement of 
the disease, however, in what may be termed its formative stage — a period 
when a correct diagnosis is of the greatest importance — to arrive at a certain 
judgment requires a careful consideration of all the vital or rational symptoms, 
and of the local physical signs indicative of the deposition of tubercular matter 
in the pulmonary tissues. The one without the other is insufiicient to render 
the diagnosis clear and positive. 

Dr. Lawson, from his own observations and experience, and the expe- 
rience of physicians generally throughout the Western States, is irresistibly led 
to the conclusion that consumption is decidedly on the increase throughout 
that portion of the United States. "It has been observed," he remarks, "in 
many localities, that tubercular disease of the lungs, although formerly rare, 
is now becoming quite common, and those observations apply to so many dis- 
tricts of country, that no doubt can remain on the subject." 

Dr. Lawson also notices, as an interesting fact, that there is a relationship, 
in point of time at least, between the increase of typhoid fever and consump- 
tion. He is not prepared to assert that there exists any direct and immediate 
connection between the causes which produce these two affections. He admits 
that their simultaneous increase may be accidental, or produced by different 
causes. 

"But," he adds, "while this maybe true, we cannot altogether disregard 
several important facts, which appear to favour the affirmative view of the 
question. At first, it is a pretty well established law, that there exists some 
degree of antagonism between miasm and pulmonary consumption, and that 
tubercular disease of the lungs is comparatively rare in paludal districts. And 
the same remark is true in reference to typhoid fever. So long as our regular 
miasmatic fevers prevail, typhoid fever is seldom witnessed ; but as the former 
subside, the latter increases. It appears evident, therefore, that in proportion 
as the miasmatic influence subsides, typhoid fever and pulmonary consumption 
increase ; and the suggestion that there may be some possible connection be- 
tween their causes, is somewhat strengthened by the observation that the 
development of tubercle not unfrequently follows a protracted attack of typhoid 
fever. Louis met with such a result in a number of cases, and Dr. Copland 
regards consumption as one of the sequelse of typhus. It has been alleged, 
also, that the product of typhus and tubercle are analogous, though of this 
there is no decisive evidence. It is proper to add, however, that Andral came 
to a different conclusion, and supposed typhus fever to be seldom followed by 
consumption. But, whatever may be the relationship of these affections, we 
know at least one important and interesting fact, namely, that they have 
increased in the same districts, and apparently under similar influences, and 
that they are both kept in abeyance by miasmatic influence.^' 

In our investigation of the etiology of tuberculosis, which has been some- 
what close and extended, we have not been able to satisfy ourselves that the 
No. LIX.— July 1855. 9 



126 



BihliograpMcal Notices. 



[July 



supposed antagonism between a miasmatic influence and the production of 
tubercle has any foundation in truth. It is very certain that tubercular disease 
of the lungs is by no means of infrequent occurrence in what are termed mias- 
matic districts of country, and where diseases universally esteemed to be of 
miasmatic origin prevail as endemics. From among a very large amount of 
direct testimony in support of this fact, which might be adduced, we quote the 
following. It occurs in the report on the Epidemics of Tennessee and Kentucky, 
made to the American Medical Association at its session of 1853. The state- 
ment is by Dr. George E. Grant, of Memphis, Tenn. 

" It is believed, and asserted by high authority, that phthisis pulmonalis is 
not only not so prevalent in malarial as in non-malarial regions, but also that, 
by a residence in localities confessedly abounding with malaria, the consump- 
tive invalid might even hope and expect a radical cure. An inspection of the 
table herewith sent w^ill show, as far as it goes, that facts are not in accordance 
with this opinion; that the disease is undeniably on the increase in Memphis, 
where malaria is almost as abundant as in the ' Pontine Marshes.' Nor is this 
all. An examination of the mortuary table not only shows that consumption 
is the only disease which has consigned victims to our cemeteries in every 
month of the past year, but it likewise informs us that precisely one-haJf of 
the 54 deaths reported to have died of it occurred from July to October, in- 
clusive, the very season of the year when malaria is in most abundance, and is 
exerting its power to the fullest extent. 

" No one will run the risk of making himself so justly subject to ridicule as 
to say that these are strangers, who have come hither to spend their summers 
on account of the healthfulness of the place.'' 

The same gentleman, in the report on the epidemics of the same localities, 
made to the Association in 1854, uses the following emphatic language : — 

"Will it not appear almost incredible that, as far south as the 35th degree 
of latitude, in a region notoriously subject to bowel complaints and to the pre- 
valence of the paroxysmal fevers, two diseases of the lungs — pneumonia and 
consumption — should prove to be the cause of nearly one-fourth, or twenty-five 
per cent, of the mortality ? It would scarcely be credited did not figures de- 
monstrate the truth of the statement.'' 

Add to this the testimony of Dr. Drake, who, in his work on the Diseases of 
the Interior Valley of North America, after a careful review of the whole sub- 
ject, makes the general statement: "In those regions where periodical fevers 
prevail, consumption is, also, a prevalent disease." 

It is not our intention to enter into a review of the practical diagnosis of 
pulmonary tuberculosis as laid down in the paper before us. It presents no pro- 
minent points for notice or criticism, and little that is not familiar to every 
well-instructed and experienced practitioner. 

The general phenomena indicative of the first stage of tubercular deposit in 
the lungs described by Dr. Lawson are: 1. Emaciation; 2. Persistent dry 
cough ; 3. Infra-clavicular depression ; 4. Diminished expansion ; 5. Dulness 
on percussion ; 6. Increased vocal fremitus ; 7. Altered respiratory murmur — 
weak, jerking, harsh, bronchial, prolonged expiration ; 8. Dry crackling. The : 
existence, he remarks, of these signs, or a fair proportion of them, may be re- j 
garded as positively indicative of tubercular deposits. 

"The preceding observations refer," says Dr. L., "to ordinary crude tuber- 
cles, as they are deposited in masses ; but there is another form, denominated 
miliary tubercles, which presents difi'erent and less distinct phenomena. 

" Auscultators are by no means agreed as to the signs which indicate the 
presence of miliary or solid tubercles, and it is generally admitted that no fixed 
and distinctive phenomena exist. Dr. Skoda declares, indeed, 'that there are 
no distinct signs by which we can with certainty diagnose the existence of 
acute miliary tubercles.' Dr. Walshe admits the difficulty of diagnosticating 
miliary tubercles, but adds, that the real difliculty consists in distinguishing 
miliary phthisis from typhoid fever. 

" My own observations on this subject have been made with much care, and 
I have been able, in a number of instances, to diagnosticate the existence of 



1855.] 



Transactions of the Ohio State Medical Society. 



127 



miliary tubercles, which, unfortunately, was confirmed by post-mortem ex- 
aminations. 

" The characteristic signs, or those on which I chiefly rely, are, persistent 
dry cough ; quick, but usually feeble pulse, with general febrile action ; slight 
incompleteness of pulmonary crepitant or finely sub-crepitant rhonchus. Dul- 
ness is not appreciable, except in very advanced stages. The existence of the 
crepitus, extending to the base of the lungs, without the accompanying signs 
and symptoms of either pneumonia or bronchitis, is as characteristic of acute 
miliary tuberculosis as dry crackling is of tubercles in masses. The degree of 
the febrile movement, which is an exact measure of the acuteness of the dis- 
ease, will vary with different cases, but it is nearly always greater than in the 
ordinary forms of consumption. 

"It is altogether possible that there is a stage of incipiency in this variety, 
in which there will be neither sufficient fever, embarrassed breathing, nor 
altered murmur, to enable us to make a diagnosis ; but, when a little more ad- 
vanced, I am satisfied that in the phenomena which I have mentioned will 
usually be found their concomitants.''^ 

There is much truth in the following remarks of Dr. Lawson — they deserve 
the serious consideration of every practitioner. It is in the removal of the 
diathesis, the morbid condition of the organism upon which the tendency to 
the deposition of tubercular matter in the tissues of the body depends — the 
tubercular predisposition, as it has been termed — that our success in the cure of 
consumption will depend. We have, heretofore, too much neglected this 
*' beginning of the evil,^' and have almost invariably directed our efi'orts to 
arrest the results of the disease, the morbid deposit and the consequences 
resulting from its presence in important organs, rather than the disease itself. 

"It is a melancholy fact," observes Dr. L., "that, thus far, consumption has 
almost defied the skill of the physician and the potency of medicines. No 
climate, age, or condition is exempt from its insidious ravages ; the robust and 
athletic man, the mere infant, young and old, though not equally liable, are. 
nevertheless, but too often victims of the disease. Bred in the very composi- 
tion of the tissues, bone and muscle, membrane and blood, all become contami- 
nated, and finally decay and die, as the inscrutable disease spreads throughout 
the system. There is a period, however, when the disease consists, not in a 
morbid deposit, but in what has been and still is called a diathesis, and this is 
the period when our remedies may be most successfully employed, before a 
fatal disorganization takes place. This constitutional predisposition has been 
most erroneously and fatally called a functional condition, and not actual dis- 
ease; and until that error is corrected and a different doctrine embraced, I 
greatly feai we shall have but little more success in the cure of phthisis than 
our predecessors. That the condition which has been called the tuberculous 
constitution or diathesis is something more than functional disorder, is clearly 
proven by the analysis of the blood, the examination of the tissues, and the 
general physical conformation. Long anterior to the deposit of tubercles, the 
blood is found deficient in globules, haematin, and iron, with an excess of albu- 
men and water, and altered or depraved fibrin. This, and but little more, 
exists during the first stage of tubercular deposits ; and yet it is averred that 
this is not disease, but a mere tendency to it. The truth is, the tuberculous 
constitution is a positive disease, which is exhibited in a changed condition of 
the blood, and of many of the solid tissues. 

"I do not deny the curability of consumption, especially in an early stage; 
on the contrary, there is, doubtless, a fair proportion of cases, treated judi- 
ciously and at an early period, and even pretty far advanced, radically cured, 
and others, for a time, suspended. But while this is true, we neglect too often 
the golden opportunity of doing good, by failing to recognize the constitutional 
derangement as positive disease, and thus wait for fatal organic lesions of a 
secondary character, before our agents are applied. The hope of the profes- 
sion still seems to be that a great specific may yet be found capable of curing 
all cases, and in all stages; but the hope is as vain as the assumption is prac- 
tically mischievous and fatal. Our country is now deluged with cod-liver oil, 
and the professional man is apt to conclude that he has done his whole duty 



128 



BibliograpMcal Notices. 



[July 



when this nauseous drug has been freely given. But I fear that experience is 
here again at fault. No modern practitioner can have more confidence in the 
cure of consumption with cod-liver oil than had Beddoes in the use of digitalis 
in that affection. But whatever may be the true merits of cod-liver oil, it is to 
be greatly feared that the present indiscriminate mode of employing it can 
hardly fail to be productive of as much harm as good, and that the mortality 
of consumption will not, in the slightest degree, be diminished by its intro- 
duction.'' 

The paper of Dr. Lawson is followed by an interesting report on Surgery, by 
Dr. G. V. Dov^ej, of Piqua. After some very judicious introductory remarks 
in reference to the causes which led to a separation between medicine and 
surgery, and on the importance of the study and practice of the two being 
combined, the reporter considers briefly the management of fractures and dis- 
locations, with the treatment of the diseases of the bones and joints; the sub- 
ject of amputations; injuries of the head; extirpation of tumours; wounds of 

^,th.e throat; permanent cure of hernia; the use of anaesthetics in surgical opera- 
tions, etc. etc. On each of the subjects indicated, although all are treated with 
great conciseness, the remarks of the reporter are occasionally pertinent and 
of value, though not unfrequently of too loose and general a character to lead 
to any important practical results. The cases interspersed throughout the 

^report will be read with interest. 

PhWc cannot agree with Dr. Dorsey in his defence of the propriety of inventors 
of surgical instruments securing to themselves the profit of their inventions by 
a patent, and we confess we have experienced both pain and mortification that 
so important and influential a body as the State Medical Society of Ohio, 
should, by a formal vote, declare " that it is not derogatory to medical dignity, 
or inconsistent with medical honour, for medical gentlemen to take out a patent- 
right for surgical or medical instruments.'' 

The framers of our national code of ethics have, with great propriety, de- 
clared it to be " derogatory to professional character for a physician to hold a 
. patent for any surgical instrument or medicine." There is no identity what- 
ever between the copyright of a book and the patenting of a surgical instru- 
ment or medicine. In the first case, there is no restriction upon our use of the 
knowledge, the facts, and information contained in a copyright work ; we have 
a right to make use of it in any manner we may think proper ; we are at per- 
fect liberty to apply it for our own advantage, or to communicate it to others, 
who are equally unrestrained in their employment of it. We are only pro- 
hibited from printing the work in which that information is contained. But 
not so with a patented instrument or medicine ; we may be convinced of its 
usefulness, we may fully understand its construction, but under no emergency 
can we avail ourselves of it, or recommend others to do so, unless we have pur- 
chased the instrument or medicine of the proprietor, or, at least, the right to 
use, manufacture, and vend it. Independently, therefore, of circumscribing 
within certain limits a useful invention in surgery, or an important discovery 
in therapeutics, the profits demanded as a remuneration by the inventor will 
often prove a barrier to the true value of the instrument or medicine being 
tested by repeated experimental trials. We have said nothing of the incon- 
sistency of a private appropriation, solely for self-aggrandizement, of any im- 
provement in surgery or medicine calculated to relieve human suffering or save 
human life, with that beneficence and liberality which should ever be the dis- 
tinguishing characteristic of our profession. 

The report concludes with some pertinent remarks on the necessity of a com- 
bined effort to remove the impediments to practical anatomy originating in the 
fears and prejudices of the community. 

A communication from Dr. G. Mendenhall, of Cincinnati, calls attention to 
some facts presented in an inaugural dissertation, presented to the Miami Me- 
dical College for the Degree of Doctor of Medicine, by E. T. Baily, of Emmetts- 
ville, Indiana, on nitric acid as a remedy for intermittent fever. 

Dr. Baily states that he has treated over ninety cases of intermittent fever 
with the nitric acid, with remarkable success ; all recovering promptly ex- 
cept ten; and, in all of these unsuccessful cases, the remedy was discontinued 



1855.] 



Transactions of the Ohio Stats Medical Society. 



129 



contrary to directions. Of the whole number of cases, fifteen were of the ter- 
tian type, and seventy-five of the quotidian. In fifty cases, there was no return 
of the chill after commencing the use of the acid. In the others, rarely more 
than one paroxysm occurred, and in no case a third. When a paroxysm 
occurred after taking the medicine, it was in every case diminished in intensity 
and duration. 

Dr. B.'s mode of proceeding is to give from five to eight drops of the com- 
mercial nitric acid, properly diluted, once in six hours, without regard to inter- 
missions or exacerbations. Cathartics and alteratives may be necessary, for 
the purpose of changing certain conditions of the system ; but, so far as the 
arrest of the paroxysms is concerned, the acid may be given without any pre- 
paratory treatment. 

The next paper is on the Etiology and Curability of Phthisis Pulmonalis, by 
Dr. C. Gr. Comegys, of Cincinnati. Though a mere outline, in which the seve- 
ral questions embraced in the general subjects of which it treats are rather 
hinted at than discussed, and containing little, if anything, strictly original, 
the paper is nevertheless a deeply interesting one. The views of the author 
are in the main correct, and although opposed, in many particulars, to what 
have been esteemed well-established facts, they will be found to be, very gene- 
rally, borne out by recent and more accurate observations. 

" Phthisis pulmonalis," Dr. C. remarks, " is now known to be a common 
disease in all civilized nations, and the remark may be extended, almost as 
fully, to embrace the people, whether savage or civilized, in all parts of the 
habitable globe ; but it does not prevail to the same extent in all countries ; 
and the most secure residences seem to be those so far north as to escape the 
greatest vicissitudes in the seasons. Thus in Stockholm, the deaths from this 
disease only amount to one-fifteenth of all ; while in London, Paris, and Ber- 
lin, they amount to almost one-fifth. In some of the German cities, the pro- 
portion is also much larger than in St. Petersburg. Many writers still hold 
out the idea that warm climates are comparatively exempt from this disease ; 
but since statistical research has been made, the deaths from phthisis have 
been found to be almost as common as in higher latitudes. Thus, for the east- 
ern continent, the rate is almost as great at Rome, Naples, Madrid, Lisbon, 
Marseilles, Malta, the Ionian Isles, and the north of Africa, as it is in Eng- 
land. 

" From the researches made on our own continent, the same result is esta- 
blished ; in fact, according to the statistics collected by the late Professor 
Drake from the reports of the British army, and the sanitary publications of 
some of the cities on our seaboard, the proportion of deaths from phthisis is 
greater in the south than in the north. These statistics relate to the West 
Indies, as well as to the British possessions further north. Statistics collected 
in Brazil and Martinique, by Drs. Rufz, Jobins, and Sigaud, show that it is as 
murderous in those places as in Europe or North America." 

In the Island of Cuba, we may add, the deaths from phthisis for the city 
of Havana constitute considerably more than one-fourth of the entire mor- 
tality, and for the rural districts upwards of twelve per cent. In the city of 
New Orleans, La., the deaths from phthisis constitute 9.51 per cent, of the 
entire mortality. The deaths from the disease in neither the Island of Cuba 
nor in New Orleans are chiefly confined to strangers who visit these places for 
the recovery of their health, but occur in a very large proportion among the 
native population. 

Inherited tendency to tuberculosis has been supposed the chief, almost the 
only, predisposing cause of the disease. But, while the hereditary character 
of the disease is well established, we nevertheless admit, with Dr. C, that the 
children of tubercular parents are by no means necessarily the subjects of 
phthisis. We have in numerous instances known them to entirely escape an 
attack ; while, on the other hand, very many have been its victims in whose 
families, for many generations back, on the side of neither the male nor female 
progenitors has the disease ever occurred. 

Lebert gives the result of his observations in 132 diseased families, and 
shows that in 87, or two-thirds, no hereditary influence could be traced. In 



130 



Bibliographical Notices. 



[July 



only about one-tenth of the cases occurring in his practice could Louis trace it 
to inheritance, Piorry in about one twenty-third, and Rilliet and Barthez in 
one-Kseventh. With these positive evidences before us, we are almost inclined 
to subscribe to the opinion of Dr. Comegys, that " death from phthisis, as an 
inherited disease, is the exception and not the rule." 

Dr. C. very correctly remarks that " a single bad hygienic condition cannot 
be regarded as sufficient to the production of tubercles ; it is only an associa- 
tion of several conditions that exerts a real influence." We may remark that 
the production of the tubercular dyscrasy is not the result of any rapid action 
of morbific causes, but of the slow and continued action of those influences 
which have a tendency to gradually impair the vital energies of the system — 
impair digestion and impede regular and healthy hematosis and nutrition. 

Dr. Comegys states that " the most favourable external hygienic circum- 
stances'^ will not prevent the development of tubercles. Not always, it is 
true ; moral causes, long-continued and exhausting diseases, may slowly im- 
pair the organic functions and give rise to tubercles; but the influence of even 
these causes in the production of tubercular disease may be, to a very consider- 
able extent, averted by the most favourable external hygienic circumstances. 

" The influence of the seasons on the production of tubercles," Dr. C. re- 
marks, and with great truth, "has been exaggerated more by hypothesis than 
by observation." 

"The special influence of professions or occupations in the production of 
tubercles," says Dr. C, " has not been well established." 

We believe this assertion will not be borne out by accurate statistics. In- 
door occupations of a purely sedentary character, especially those demanding 
a constant constrained position of the body ; occupations, also, which, besides 
being sedentary, call for prolonged and intense mental application, are con- 
fessedly more liable to produce tubercular disease than such as are carried on in 
the open air, and which allow the free and unconstrained exercise of the muscles 
generally ; or which occupy and interest the mind without overtasking it — 
even when every other hygienic condition is, in all of them, equally favourable. 

After endeavouring to show% what nearly all pathologists now admit, that the 
etiology of phthisis pulmonalis is to be sought in "the imperfect digestion and 
elaboration of the elements of the food consumed ;" in other words, in disor- 
dered digestion, assimilation, and nutrition — Dr. C. infers, and very correctly, 

that the number of cases that may be successfully treated, and the diatheses 
that may be combated, will depend largely upon the period at which the treat- 
ment is commenced, and the amount of control obtained in the direction of the 
functions of digestion and assimilation, and of the external conditions that sur- 
round our patients." 

The paper next in order is on the Pathology, Symptomatology, &c. of Latent 
Pneumonia, by Dr. S. G. Armor, of Cincinnati. 

This form of pneumonia is asserted to be of frequent occurrence in the ma- 
larious districts of the West, and being unattended in its early stages by the 
more prominent symptoms of pneumonic inflammation, making its approaches 
silently and gradually, its presence is often unsuspected by either patient or 
physician until the work of destruction is accomplished. There is little con- 
stitutional disturbance, so little that the patient may often pursue his usual 
occupations. 

" If the disease has made considerable progress," says Dr. A., " on being 
interrogated, the patient may complain of a troublesome, but not painful cough, 
with a somewhat viscid and scanty expectoration, the tongue moist and slightly 
furred, appetite unimpaired, respiration hurried, inability to take exercise, and 
previously to hectic symptoms, there will be found a marked disparity heitveen 
the respiration and the circulation." 

" In latent pneumonia, congestion olwajs predominates over the determination 
of blood. Hence its marked asthenic character." "There is little or no pain ; 
fever and other signs of increased action are comparatively slight ; nor does it 
tend to such speedy results as the acute variety." 

Latent pneumonia has the same stages as the ordinary disease ; they occur, 
however, more slowly, and are attended with less prominent symptoms. The 



1855.] Transactions of {he Med. and CMr. Faculty of Maryland. 131 



true crepitant rale, so constantly present in the stage of engorgement of active 
pneumonia, and even heard in the local or lobular variety, is rarely detected; 
if heard at all, it is as a muco-crepitant rale. 

Latent pneumonia is usually seated in the inferior portion of the left lung, 
extending from below upwards. 

Gangrene of the lungs is an occasional termination of the disease, especially 
when it occurs in connection with an alteration of the blood. Derangement of 
the liver, followed by jaundice, is a frequent complication. 

We present, in his own words, Dr. Armor's account of the treatment of latent 
pneumonia. 

"Caution has to be exercised in the use of all remedies which are calculated 
to depress the vital forces. Beef tea and quinia are oftener indicated than 
bloodletting and antimony. The patient's strength must be supported, the 
local hyperiemia must be overcome ; and, although to accomplish this it may 
be necessary, in some cases, to abstract blood locally by means of cups, it may 
be equally necessary, at the same moment, to husband the patient's strength 
by the administration of tonics." 

In lat-ent pneumonia, it is all-important to guard against the occurrence of 
bronchitis by pUcing the patient in an apartment of a moderately warm and 
uniform temperature, and guarding against sudden exposure to cold or drafts 
of cool air. 

*' In the more advanced stages, the moist, coarse rales are frequently heard 
over a large extent of surface. If, in connection with this physical symptom, 
the pulse be feeble, the skin dusky, cold, and relaxed, we should lose no time 
before putting the patient on the use of some of the stimulating expectorants, 
and, perhaps, none equal in importance the senega and sesqui-carbonate of 
ammonia. This combination appears to be peculiarly adapted to those cases in 
which the secretion into the tubes is considerable, and the patient expectorates 
with difficulty." 

" The sesqui-carbonate of ammonia, wine, bark, and the nutritious animal 
broths, well seasoned with the chloride of sodium, often exercise a marked con- 
trol over the local disease." 

Dr. Armor considers the effects of blisters to the chest as more certain in 
latent than in ordinary pneumonia ; and that their use may be resorted to more 
early. They should, he thinks, be small in size, and frequently repeated ; never 
being kept on long enough to produce exhausting suppuration. Counter-irri- 
tation, from the use of strong acetic acid and turpentine, he notices as also an 
important remedy. 

" Any indication of periodicity should be promptly met by the use of the 
sidphate of quinia. In malarious districts, the powers of this remedy are often 
singularly displayed in the treatment of this form of pneumonia." 

Dr. E. Thompson presents a drawing and description of two instruments, a 
"gouge bone cutting forceps," and "a hand-drill or bone perforator." The 
first he considers of great convenience and advantage in that class of operations 
on bones which has hitherto required the employment of the mallet and chisel, 
gouge, trephine, chain-saw, etc. ; and the second he offers as very useful in 
many cases. The peculiarity of these instruments cannot be understood with- 
out a reference to the drawings by which the descriptions of them are accom- 
panied. 

2. The reports of the Medical and Chirurgical Faculty of Maryland are 
only two in number — one on surgery, by a committee, of which Dr. Christopher 
Johnston is chairman: and one on medical chemistry, by a committee, of 
which Dr. Charles Frick is chairman. They are both of a very high order, 
presenting a very full and very able digest of the present state of knowledge 
in reference to several important questions in the respective departments of 
medical science of which they treat. 

The report on Surgery comprises observations on the microscope in relation 
to diagnosis and to classification in certain diseases ; the union of fractured 
tone, and the treatment of fractures ; aneurism and its treatment; and the 



132 



BihliograpTiical Notices. 



[July 



pathology and curative indications in certain ophthalmic diseases, together vrith. 
some modern instruments to assist in their detection, etc. 

The report is an extremely interesting one, and may be read with profit by 
every surgical practitioner ; especially by those whose locations are remote 
from the great centres vrhere the progress in each department of chirurgical 
medicine becomes first known and duly appreciated. The interest and value of 
the report in question do not consist in its embodying a series of original 
observations in reference to either of the topics embraced in it, but in the 
faithful, clear, and, at the same time, concise summary it presents of the 
recorded facts and deductions of the authorities of the profession. 

It would bo impossible to present any useful analysis of either of the reports 
presented at the last session of the Medical and Chirurgical Faculty of Mary- 
land ; and from that on surgery we do not think it necessary to make any 
extracts. 

The report on Medical Chemistry is restricted to the chemistry and pathology 
of the urine. 

The important physiological fact of the manufacture of sugar by the kidneys, 
as shown by the beautiful experiments of M. Bernard, and its relation to the 
pathology of diabetes is first considered. Reference is also made to the experi- 
ments of Valentin, of Bern, in which sugar was detected in the liver, blood, and 
watery contents of the stomach of marmots in whom hybernation had existed 
over two months ; as well as to the experiments of Henle, to show that "the 
nervous reflex action, upon which depends the secretion of sugar by the liver, 
is generated in the liver itself, by the stimulating power of the blood of the 
portal vein." 

The report, in noticing Regnoso's assertion that, from his observations, he has 
found the urine of most aged persons, as well as those suffering under imperfect 
respiration, to contain sugar, remarks, " this statement requires confirmation ; 
we ourselves have not been able to verify it, and, with one exception ( Chemist, 
April, 1853, p. 304), we are not aware that anyone else has done so.''' He has 
lately declared, in addition, that the urine of epileptics, after the attack, also 
contains sugar. The report before us says, that in two cases in which its 
authors have examined the urine by the means indicated by Regnoso, " they 
failed both times to detect it, so that, however general the fact may be, it cer- 
tainly is not universal, as he concludes. 

The report before us presents a very able summary of the recent facts de- 
veloped in relation to the leading subjects embraced under the general head of 
medical chemistry, including in that term both physiological and pathological 
chemistry. The report concludes with an account of some interesting experi- 
ments, "undertaken with a view of showing the influence of different remedies 
upon the urinary secretion.'" 

The experiments were performed on the inmates of the Maryland Peniten- 
tiary Hospital, during a period of nearly ten months. 

"Each inmate admitted to the hospital was subjected to the treatment that 
seemed appropriate to his disease, and without reference to the investigations that 
were being pursued. Each was provided, at his bedside, with a clean glass 
vessel of sufficient size, in which he was directed to pass all the urine he voided. 
Daily measurements of these amounts were taken, the specific quantity ascer- 
tained, and, after recording them, the particular remedy, or combination of 
remedies, with the doses, was set opposite to each name. Subsequently, from 
these tables the amount of solids was calculated, and the deductions then made 
which are herein embodied. In this way nearly 2,000 separate observations 
were collected with very little trouble ; but as, in many instances, the treatment 
was of too complicated a nature, or of too short duration, to allow of any proper 
conclusions being drawn, a large number of these were rejected, and the tables 
here presented are made up of about 1,200 separate observations. "STe might 
remark here that the largest quantity of urine and solids the tables record, is 
100 ounces, containing 2,800 grs., more than three times the average amount. 
And that in no single instance of the 2,000 did we ever detect sugar, although 
a very large number were examined with this view — a result entirely opposed 
to the statements of Regnoso. 



1855.] Transactions of the 3Ied. and CJiir. Faculty of Maryland. 133 



** The conclusions here presented are average results obtained from the ex- 
amination of a large number of cases taking the same remedy, without reference 
to the disease under which they were labouring. In but one or two of the ave- 
rages were a less number than 50 taken, and in one more than 100. It may be 
objected that the influence of disease, a most important consideration, is here 
omitted. But this omission is almost unavoidable, and from the fact that the 
different diseases bear nearly the same proportion to each individual remedy, 
this element becomes in a measure equalized, and does not interfere with the 
correctness of the conclusions, as might at first be anticipated. 

*' We might also remark that the amount of solids, as deduced from the spe- 
cific gravity, is not exactly correct, but still sufiiciently so for comparison ; and 
that the amount of solids, as well as of fluid, is less than it ought to be in 
every instance, as no account could be taken of the quantity passed w^hile at 
stool. 

"The quantity of urine in a healthy man varies from 20 to 60 ounces, con- 
taining from 400 to 1,600 grains in the 24 hours, and often much beyond these 
limits. The cause of these variations are partly internal, and partly external — 
some transitory, others of a longer duration — some simple, and others compli- 
cated. Of these, the influence of drink is most remarkable. It may increase 
the secretion, within four hours, to three or even ten times its normal amount. 
The quantity voided at night is generally the least, while in the morning it 
increases, and in the afternoon or evening attains its maximum. As regards 
the quantity secreted in diseases, it is found to be normal in most chronic affec- 
tions unattended with fever. It does not often exceed the usual quantity, and 
is diminished in most diseases. This diminution, to the greatest degree, is 
found on an average in the acute fevers.'^ 

We present, in tabular form, the result of the experiments referred to — 



Substances employed. 

Sulph. quinisa and 
sulph. ferri, 

Juniper tea, 

Prussiate of iron, 
Sulphate of iron, 
Phosphat. ammonise 

and wine of colchi- 

cum, 

Acetate of potass. 

Decoction of Peruvian 

bark. 
Wine of colchicum. 

Gin, 

Whiskey, 

Phosphate of ammonia, 
Mur. tinct. ferri, 
Iodide of potass. 
Sulph. quinias, 

No medicine. 

Phosphate of lime, 
Spir. nit. ether, 
Strychnine and mur. 

tinct. ferri, 
Cod-liver oil, 
Morphia, 
Strychnine, 



Quantity given. 

3 grs. of first, and 1 of 
second, 

4 oz. berries to a quart of 
water in the 24 hours. 

4 grs. 3 times daily, 

1 gr. 3 times daily, 

20 grs. of first, 15 drops 
of second. 

r from \ drachm to \ ounce 
\ in one quart water 
[ daily. 

I 2 drachms to a quart of 
[ water, \ pint daily, 

15 drops 3 times daily, 
f 2 oz. in water, in divided 
I doses, daily, 

in the same quantity. 

10 grs. 4 times daily, 

45 drops daily, 

15 grs. daily, 

12 grs. daily, 
r persons labouring under 
\ disease requiring no in- 
( ternal medication, 

12 grs. daily, 

half drachm daily, 

gr. of first and 15 drops 
of second, 3 times daily, 

2 oz. daily, 
i gr. daily, 

gr. three times daily, 



Number 
of analyses. 



Urine in Solids 
ounces. in grains. 



48 


57 


1248 


39 


56 


1134 


52 


52 


1095 


53 


53 


992 


42 


42 


936 


110 


40 


926 


93 


49 


925 


47 


39 


893 


17 


■ 51 


853 


22 


47 


842 


43 


38i 


834 


48 


52 


810 


63 


41 


809 


57 


39 


801 


71 


34 


795 


19 


36 


792 


51 


37 


782 


48 


33 • 


725 


63 


38 


720 


48 


32 


627 


53 


29 


500 



134 



Bibliographical Notices. 



r [July 



3. In the report on Hospital Hygiene, Dr. Griscom presents a striking illus- 
tration of the virulence of the morbid exhalation from the bodies of patients 
labouring under low forms of fevers, when such patients are congregated in 
hospitals, even when the wards of these are apparently not deficient in respect 
to size and elevation, nor absolutely defective in means for ventilation, as well 
as of the tenacity with which the poison thus generated adheres to the atmo- 
sphere and walls of the apartments where it was generated. 

In the building attached to the New York Hospital, up to January, 1852, 
immigrants labouring under typhus fever had been received in considerable 
numbers, some to spend merely a night previously to their removal to the fever 
hospital on Staten Island, and others as permanent patients. This building 
would be regarded by almost any person who should visit it as possessing, in 
elevation, general situation, and internal arrangements, advantages superior to a 
great majority of buildings devoted to hospital purposes. In January, 1852, 
however, the atmosphere of the whole house seemed to have become thoroughly 
infected ; patients with rheumatism, or other benign complaints, began to suc- 
cumb to the power of the pervading miasm, even in some of the wards into 
which no typhus cases had been admitted. 

" Notwithstanding that thorough cleanliness, and as free ventilation as pos- 
sible, were maintained, and the immigrant cases were rigidly confined to their 
particular apartments, the difficulty increased to such a degree as at last to 
render necessary an entire change in the economy of the establishment with 
respect to this disease. At the suggestion of the visiting physicians, the 
Board of Governors, first, prohibited the reception of any more immigrant night 
cases ; and secondly, a thorough purification of all the typhus wards was 
ordered. The number of patients was reduced, so as to allow one or two wards 
to be vacated, and successively the infected rooms were disinfected, and ex- 
posed to the external air night and day for several weeks, until the whole was 
renovated.'^ 

In this work of purification, four men, three masons and a laborer, were em- 
ployed to cleanse the walls and ceilings, and whitewash them where necessary. 
" They wrought only in the wards which had been vacated, and then only after 
each had been thoroughly aired by open doors and windows. These men did 
not enter any of the wards occupied by the sick ; they had no occasion, in going 
to and fro, to see any part of the premises but the large halls, the stairways, 
and the apartments they were at work in. They were engaged there one week. 
The labourer passed a great deal of his time in the open air, preparing and 
carrying materials for the others, and hence visited the building only occasion- 
ally, remaining but a short time in it, except when, being otherwise unoccu- 
pied, he aided the others a little at their work.'' 

Within six days from the period when they finished their work at the hos- 
pital, three of these men were attacked with typhus fever, of whom two died. 
They were treated at their own homes, which are represented as having been 
comfortable residences, and they were all temperate and respectable persons. 

In contrast to the foregoing, and as an evidence of the beneficial influence of 
free ventilation in disarming typhus fever of its infectious and malignant cha- 
racter, the following is related by Dr. G. : — 

In the month of August, 1837, a number of ships with immigrant passengers 
arrived at Perth Amboy, from Liverpool and other ports, on board of which 
ship fever prevailed. There was no hospital or other accommodation in the 
town, in which the sick could be placed, and no person would admit them into 
private dwellings, fearing the infection of the fever. They could not be left 
on board the ships. An arrangement was made to land the sick passengers, 
and place them in an open wood, adjacent to a large spring of water, about a 
mile and a half from the town. Rough shanties were erected, two in number, 
thirty feet long, twenty feet wide, boarded on three sides about four feet up, 
covered with sails, and floored. Thirty-six patients were taken from on board 
ship with boats, landed as near the spring as they could be got, and then carried 
in wagons to the shanties, under the influence of a hot sun, in the month of 
August. Of the thirty-six landed, twelve were insensible, apparently in the 
last stage of ship fever, and not expected to survive twenty-four hours. The 



1855.] Transactions of the New York Academy of Medicine. 135 



day after landing, there was a heavy rain, and the shanties affording no pro- 
tection with their " sail roofs," the sick were found the next morning wet, and 
their bedding, such as it was, drenched with the rain. It was replaced with 
such articles as could be collected from the charity of the inhabitants. The 
number at the encampment was increased by new subjects to the amount of 
eighty-two in all. On board of one of the ships, which was cleansed after land- 
ing the passengers, yb?ir of the crew were attacked with fever, and two died. 
Some of the nurses at the encampment were taken sick, but recovered. Of the 
whole number of the eighty-two passengers removed from the ships, not one 
died. Pure air, good water, and perhaps the rain — though only the first thirty- 
sis were exposed to it — seem to have effected the cure. " The medical treat- 
ment," remarks Dr. C. M. Smith, who had charge of the patients, " was exceed- 
ingly simple, consisting, in the main, of an occasional laxative or enema, 
vegetable acids and bitters ; wine was liberally administered, together with the 
free use of cold water, buttermilk, and animal broths." The four sailors, who 
sickened after the arrival of their vessel, were removed to the room of an ordi- 
nary dwelling-house ; the medical treatment in their case was precisely simi- 
lar, yet two of them died. Two of the patients suffered from carbuncle while 
convalescing. Dr. S. adds: " My opinion is that, had the eighty-two treated at 
the encampment been placed in a common hospital, many of them would also 
have fallen victims. I do not attribute their recovery so much to the remedies 
administered as to the circumstances in which they were placed ; in other 
words, a good washing to begin with, and an abundance of fresh air." 

Dr. Griscom regards the first of the cases just related as " presenting a type 
of the average hygienic character of hospitals in general as they are; the last a 
type of what they should he, in this respect, excepting, of course, the materials 
and style of structure. 

" Regarded in its general aspect as a source of light and health," says Dr. 
G,, "an ample supply of pure air, in conjunction with the immediate removal 
of secreted and exhaled impurities, beyond the possibility of a re-inhalation, is 
a subject of profound interest to all humanity ; but to the practitioner of medi- 
cine it presents itself with increased force. There is imposed upon us a double 
obligation. The question should be constantly before our minds, whether we 
shall deny, or allow to be denied, to our patients, the use of oxygen in the 
fullest measure in which it can be found in the atmosphere? Whether, while 
searching our materia medica for the most appropriate remedies, according to 
our theories of disease and treatment, we will continue to overlook the most 
potent of all restoratives, that derived from Nature's own laboratory ?" 

" Let it never be forgotten for a moment that this agent — to procure which 
we have neither to dig into the earth, nor transport from foreign climes, nor 
distil from the alembic, nor refine in the crucible, but which is pressed upon us 
with a force and in a measure equalled only by the supreme benevolence which 
furnishes and unceasingly renews it ; this agent, when left free to act its part, 
removes the effete poison from the blood, and imbues it with continual health 
and freshness, but when stifled and confined, whether intentionally or by acci- 
dent, turns, like a viper, upon the arm that nourished it, and plants a deadly 
venom in its veins." 

The report on Solidified Milk, though ostensibly emanating from the Com- 
mittee on Public Health and Legal Medicine, is, we suspect, from the pen of the 
same gentleman to whom we are indebted for the preceding one on Hospital 
Hygiene. 

Every means adapted to" preserve for a length of time, and in a portable form, 
those alimentary substances necessary for the support of human life, or which 
add materially to his real comforts, especially such substances as quickly dete- 
riorate, either by the action upon them of external atmospherical influences or 
by the spontaneous reaction of their own elements, is a subject of deep interest. 
In the various circumstances in which man may be placed, it is possible for 
him to be removed for months and even years beyond those sources from which 
a supply can be obtained of the food necessary for his sustenance, in that un- 
altered condition upon which its palatableness and wholesome qualities mainly 
depend. It is conferring upon him, therefore, an essential benefit to supply 



136 



Bibliographical Notices. 



[July 



him with necessary food and alimentary luxuries in a form of concentration 
and durability in which their natural flavour and wholesome nutritious pro- 
perties remain unimpaired. 

" As an article of food, under all circumstances of life, civilized and barba- 
rian, in infancy and in age, in sickness and in health, milk is at once a luxury 
and a necessity ; and it is remarkable that, being such, it, of all the sources of 
man's sustenance, should be the most susceptible of spontaneous decomposi- 
tion, and this not so much from the influence of the atmosphere or any other 
external agent upon it, as from its own innate tendency, arising from its com- 
plicated and peculiar organization; a few hours, and, in warm weather, even a 
few minutes, being sufficient to change its constituent character. Any method 
to preserve the integrity and nutritive qualities of milk, so that it may be avail- 
able at anytime as diet, must therefore, if successful, be regarded as among 
the most interesting and valuable of the gifts of science to humanity." 

The committee, whose report is before us, state their belief, derived from a 
very thorough examination of the whole subject, that this most desirable object 
has been attained by a simple and ingenious process devised by Mr. S. J. 
Blatchford, of Dutchess County, N. Y., who manufactures and supplies for sale 
solidified milk, which the committee have ascertained to be the solid constitu- 
ents of pure milk, combined with a little less, by weight, of white sugar. 

"It contains," they assure us, "no other foreign substance." The various 
solids of the original fluid are preserved intact, even the butter globules being 
unbroken. It is readily and perfectly soluble in water, and when so dissolved 
in proper proportion, it is, in fact, milk, as it was secreted by the cow, with 
the sole exception of the sugar which accompanies it; and the only medicinal 
or culinary operations in which ordinary milk is required, and the solidified 
article cannot be used, are those in which sugar is inadmissible ; on the other 
hand, whenever sugar is required in connection with milk, they are here found 
together. 

"Blatchford's Solidified Milk comes to us mainly in the form of a tablet, 
covered with tin foil. It has a light yellow, slightly mottled appearance, is of 
a very firm texture, but yields readily to the knife or grater. Each tablet 
weighs a pound, and will make in solution five pints of rich milk. When pul- 
verized, it is readily soluble in hot or tepid water, while cold water requires 
rather longer time, but the solution is perfect in either. The tepid solution 
approaches nearer the standard of natural milk. The only objection, besides 
that of the presence of sugar, which can be made to it, is an empyreumatic 
flavour somewhat similar to that of boiled milk, which it receives in the process 
of manufacture. This varies in degree, but it is much less distinct when the 
solution is made with cold than with hot water ; and in the preparation of cus- 
tards, puddings, arrowroot, wine whey, ice creams, &c., in all of which the 
committee have practically tested, it disappears. To many persons, this 
flavour is not objectionable, and with many others the palate soon becomes re- 
conciled to it, and in a short time fails to recognize it. By contemplated im- 
provements in the apparatus for manufacturing it, this objection is expected to 
be entirely obviated. 

"A solution in cold water, allowed to stand sufl&ciently long, will exhibit a 
surface of rich cream, much more abundant than is found in the same quantity 
of milk carefully selected in the city ; from this cream your committee have 
caused good butter to be made, from which all traces of sugar are easily washed 
away, showing that this substance is only mechanically, and not chemically, 
incorporated with the milk constituents. In solution, it does not acidify so 
soon as the milk of city consumption. 

" Besides the hard tablet, the solidified milk is also furnished in a granular 
form, inclosed in cans ; it is thus more convenient for use, and will doubtless 
keep sweet for many months, though probably more liable to change than in 
the other form." 

P. F. C. 



1855.] American Insane Hospital Reports. 137 



Art. XYI. — Reports of tJie American Institutions for the Insane. 

1. Of tJie Neiv Hampshire State Asylum, for 1852 and 1853. 

2. Of the McLean Asylum, for 1853 and 1854. 

3. Of the Retreat at Hartford, for 1853. 

4. Of the Asylum for the Poor, BlackioelVs Island, N. Y. City, for 1853. 

5. Of the Indiana State Hospital, for 1853 and 1854. 

6. Of the Illinois State Hospital, biennial for 1853-54. 

7. Of the Missouri State Asylum, biennial for 1852-53. 

1. In J uly, 1852, Dr. Andrew McFarland resigned the office of Superintendent 
of the New Hampshire Asylum for the Insane, having, in the language of the 
Trustees of the Institution, *' with signal ability and devotion, discharged the 
duties for about seven years." He was succeeded by Dr. John E. Tyler, in 
whom the Trustees believe that they have " a judicious, efficient, and devoted 
Superintendent." 

The report of Dr. Tyler for the fiscal year ending on the 31st of May, 1853, 
seven months after he became connected with the Asylum, is limited to about 
half a dozen pages, and contains but little matter of general interest to medical 
men. It is a very prudent and sensible production for a beginner. 

Men. Women. Total. 

Patients in the Asylum May 31, 1852 
Admitted in course of the year 

Whole number 

Discharged, including deaths 
Remaining May 31, 1853 . 
Of those discharged, there were cured 
Died ....... 



63 


55 


118 


68 


64 


132 


131 


119 


250 


61 


46 


107 


70 


73 


143 


41 


22 


63 


5 


3 


8 



Dr. T^der complains that the number of patients is so great as to prevent a 
proper classification of them. 

The report for the year ending May 31, 1854, is somewhat more extended 
than its immediate predecessor, but is, in a great measure, confined in its sub- 
jects to the materiel of the establishment, and to topics already familiar to our 
readers. The doctor complains of the pressure from without of patients, and 
proposes that an additional wing and a building for the violent shall be erected. 
" The house is now lighted with gas, and we not only find its use more conve- 
nient, comfortable, and cleanly than oil, but its brilliant light a curative means 
in making our previously half-lighted halls cheerful and pleasant." He says 
nothing of the comparative expense. 

Men. Women. Total. 

Patients May 31, 1853 
Admitted in course of the year 

Whole number 

Discharged, including deaths • . 
Remaining May 31, 1854 . 
Of those discharged, there were cured 
Died 



70 


73 


143 


72 


69 


141 


142 


142 


284 


67 


56 


123 


771 


84^ 


161 


34 


29 


63 


7 


7 


14 



The whole number of patients exceeds that of any previous year by 64. 

"During the whole year our household has enjoyed remarkable physical 
health. We have been entirely exempt from epidemics of all sorts, and acute 
disease has been almost unknown. Cleanliness, regularity of life, and a most 
healthful location, have been the chief causes of this desirable state of things. 
The deaths which have occurred, with a single exception, were of those who 



' According to the previous figures, these should be 75 and 86. 



138 



Bihliograijliical Notices. 



[July 



for a long time had "been considered incurably insane, and who at last were 
literally worn out by the continued and unremitting force of their malady." 

Patients admitted from 1843 to 31st May, 1854 . . 1,199 

Cured 497 

Died 106 

2. Dr. Bell, of the McLean Asylum, has written but few reports of any 
length, and in the two which are now before us he is even unusually brief, 
both of them occupying but about a dozen pages. One reason of this brevity 
is mentioned in the extract which we subjoin, merely remarking that, although 
it may be good and sufficient for the district from which the McLean Asylum 
is principally supplied with patients, it is hardly equally so for many other 
sections of the country. 

" There was a period in the history of the institutions for the insane of this 
country when their annual reports were looked for with an interest natural to 
a new topic, and when so many communities were about engaging in. the great 
work of providing for the insane, that all information which could throw light 
upon the path of duty was eagerly and gratefully accepted. That time is 
now passed, for the demand has been essentially met, and good taste and pro- 
priety are no longer in antagonism with philanthropy, as to spreading to the 
world the often painful incidents connected with a sad disease and its victims. 
It would ever be an easy service to furnish a prolonged and interesting narra- 
tive of the cases of an asylum, were the motives now allowable which formerly 
justified such communications with the public.'^ 

Men. Women. Total. 



Patients at the commencement of 1853 . . 201 

Admitted in course of the year ... 61 53 114 

Whole number . . . . . . . 315 

Discharged, recovered ...... 30 28 58 

Died 7 10 17 

Remaining at the close of 1853 . . . 195 



"From a minute, kept during a portion of the year," says the report, " it is 
probable that we have been obliged to refuse three times as many patients as 
have been received.'^ 

It will be remembered by those who have read our previous notices that Mr. 
Appleton gave a large fund to this institution, for the purpose of constructing 
apartments specially intended for persons able and willing to pay a liberal 
remuneration for their accommodations. The object of the donor has been 
partially accomplished. The "Appleton ward^' for men has been completed, 
and in reference to its operation we find the subjoined remarks : — 

" The patients themselves, in these rich and spacious quarters, can draw no 
unfavourable comparisons with their situations at home, and are spared one 
pang in the distress incident to their disease. The only drawback suggested 
or anticipated — that the patients who did not enjoy the new accommodations 
might indulge a certain sentiment of jealousy towards their more fortunate 
associates — has never been manifested.-" 

Report for 1854:— 

Men. "Women. Total. 



Patients at the commencement of the year . 94 101 195 

Admitted in course of the year ... 70 50 120 

Whole number 1C4 151 315 

Discharged, including deaths .... 67 53 120 

Remaining at the close of the year ... 97 98 195 

Of those discharged, there were cured . . 32 27 59 

Died 5 11 16 



The McLean Asylum was opened on the 6th of October, 1828. It was under 
the superintendence of Dr. Wyman about sixteen years, and of his successor, 
Dr. Lee, two years. Dr. Bell has been the incumbent of the office since the 



1855.] 



American Insane Kospital Reports. 



139 



commencement of 1837, a period of eighteen years. We "believe this to be the 
longest term of service of any ofl&cer who has occupied an of&ce of the kind 
in this country. 

Patients admitted under Dr. Wvman . . 1,122 

Dr. Lee ... 189 

Dr. Bell . . . 2,572 

Whole number admitted 3,783 

Discharged, including deaths .... 3,588 

Cured 1,802 

Died 322 

" I cannot but believe,'^ remarks Dr. Bell, " that the time is near when the 
necessity of dividing this asylum, and establishing a department for one sex 
elsewhere in the vicinity, will result in action. The financial experience of 
this establishment, for many years past, would seem to demonstrate that the 
first outlay for such an addition to the means of treatment of those classes of 
the insane who are now mainly received here, would be all the demand needful 
upon the philanthropic and liberal of our community.'-' 

3. The last report, from the Betreat at Hartford, Connecticut, which we 
passed under review, was issued during the absence of the Superintendent, Dr. 
Butler, upon a European tour. The one now before us bears his signature. 



Patients in the Retreat March .31, 1853 
Admitted in course of the fiscal year 

Whole number 

Discharged, including deaths 
Remaining March 31, 1854 
Of those discharged, there were cured 
Died 



Men. "Women. Total. 



80 


90 


170 


74 


103 


177 


154 


193 


347 


65 


96 


161 


89 


97 


186 


22 


42 


64 


13 


9 


22 



The Retreat was opened on the 1st of April, 1824. For ten years it was 
under the superintendence of Dr. Todd, six years under Dr. Fuller, and three 
years under Dr. Brigham. At the date of this report it had been eleven years 
under Dr. Butler. 

Patients admitted in course of the term of Dr. Todd . . 520 

Dr. Fuller . 481 

Dr. Brigham . 246 

' " " " Dr. Butler . 1,388 

Men. Women. Total, 

Whole number admitted . . . . 1,266 1,369 2,635 

Cured 1,331 

Died 265 

Thus the deaths of cases, during thirty years, was 10.05 per cent. But, upon 
reference to another table, we find that the whole number persons who made 
up these 2,635 cases was but 1,798. Of these 1,798 persons, 248 were admitted 
twice each, 65 three times, 17 four times, 10 five times, 4 six times, 1 seven 
times, and 1 nine times. Of persons, 265 died, which is 14.73 per cent. 
The proportion of cures, upon admissions, was 50.05 per cent. But the same 
person may, in many instances, have been cured two or three times, and, in 
some instances, four, five, or six times. The report throws no light, even by 
comparison of tables, upon the number of persons cured. This is an imperfec- 
tion which, as we have heretofore remarked, pervades nearly all the American 
statistics of insanity. 

One further illustration, which we overlooked until the last preceding sen- 
tence was written. Dr. Butler states that the percentage of deaths on the 
whole number discharged since the opening of the institution is 10.82. This 
is correct, if calculated upon the number of cases. But what is the result, if 



no 



BihliograpTiical Notices. 



[July 



otherwise regarded? Of 1,798 persons admitted, 186 remain in the asylum. 
Hence 1,612 have been discharged. Of 1,612 persons discharged, 265 died, 
equal to 16.43 per cent. 

Of 1,203 cases admitted since March 31, 1845, the age, at the time of first 
attack, was between 20 and 30 years in 402 ; between 30 and 40 years in 240. 
The excess of the former is equal to 66 per cent. 

The causes of death in 196 cases, which have occurred since the 31st of 
March, 1841, were as follows : Exhaustion 36, dysentery 21, general debility 
19, phthisis 14, apoplexy 12, general paralysis 12, paralysis 10, erysipelas 10, 
disease of the brain 9, old age 7, marasmus 7, suicide 7, " disease of lung'' 5, 
epilepsy 4, inflammation of bowels 4, fever 3, internal hemorrhage 3, chronic 
diarrhoea 3, "injury'^ 2, disease of heart 2, psoas abcess 1, inflammation of 
' liver 1, disease of uterus 1, acute diarrhoea 1, dropsy 1, cancer 1. 

After stating that "neither order of court, certificate of physicians, nor writ- 
ten application of friends or relatives'' is required for getting a patient into 
the Retreat, and that " the admission rests solely upon the judgment of the 
superintendent," Dr. Butler very properly appeals to the Board of Directors to 
remove the responsibility from him, and place it upon the friends and the 
attending physician of the patient. Where are the Connecticut lawyers, judges, 
and legislators, that such a weak point in the barriers of the rights and liber- 
ties of the people has thus long remained unguarded? 

The remarks of Dr. Butler upon the condition in which patients come to the 
Eetreat close with this passage, which we earnestly commend to the notice and 
the memory of every physician in general practice : " Others, worse than all, 
have been brought here by the ill-judged and most pernicious means of decep- 
tion, the effect of which has been, in every case that ever came under my 
observation, both annoying to ourselves and detrimental to the poor sufferer. 
' How can I believe you, sir,' said a gentleman to me, while trying to soothe him, 
' when these, my friends, have lied to me every mile of my way here f " 

No apology is required for making the subjoined extract, albeit somewhat 
longer than we are wont. 

"During the six months' vacation which was so kindly granted me by the 
liberality of your Board, I had the pleasure of being able to visit many of the 
most prominent lunatic hospitals in England and Scotland. I embrace this 
■opportunity to express my grateful sense of the cordiality and courtesy with 
which, as the superintendent of one of the oldest lunatic hospitals in thetlnited 
States, I was everywhere received, and of the frankness and promptitude with 
which the details of the different institutions were shown. Every door was 
opened, and every department freely exhibited, evidently giving me the credit 
of coming to learn the advantages of their institutions, and not to seek for 
demerits or matters of cavil. 

" My reception at some of them was more like that due to an old friend than 
to a stranger, and was a pleasant recognition of that kindly community of 
feeling which springs up in every liberalized mind towards those who are fel- 
low-labourers in the same great commonwealth of philanthropy. 

" It is evident that, from a variety of causes, a spirit of improvement is per- 
vading these hospitals. A great impetus has of late years been given to this 
department of human effort, and the most beneficial and gratifying results have 
been attained. 

" It is not expedient, in the narrow limits to which I desire to restrict this 
report, to go into a consideration of these causes. It is sufficient for my pur- 
pose to say that, notwithstanding a few years since our leading institutions 
were not surpassed by the best of theirs, it is very evident to me that we have 
now none which will compare with some of those lately erected there. In the 
older hospitals, there was manifest improvement in the buildings where ori- 
ginal defects could never be wholly remedied. In the new institutions, those 
erected within a very few years, or just now going into operation, I found a 
beauty of structure, with a thoroughness and perfection of arrangement which 
I have never seen equalled elsewhere. Among these it will not, I hope, be 
invidious to mention the asylums at Prestwich and Cheadle, near Manchester ; 



1855.] 



American Insane Hospital Reports. 



141 



at Mickleover, near Derbv ; at Clifton, near York ; and the new asylum at 
Stafford. 

" It was evident that in these new asylums no pains nor needful expense 
had been spared to obtain, in the first place, the most unexceptionable plans. 
The highest authorities were consulted, and their conclusions referred to the 
scrutiny of other practical men ; the errors of preceding structures were avoided, 
and every improvement as readily adopted, with the single desire to obtain the 
best. It is evident that, generally, each succeeding structure contains im- 
provements upon its predecessors. Once adopted, the plans have been carried 
out without that curtailment and distortion which sometimes, in this country, 
has produced such unfortunate results. In some instances, it is evident that 
undue expenditure has been incurred to produce external effect ; but in the 
internal arrangements, especially, it is clear that, while in county as_ylums 
everything is plain and simple and unpretending, that is deemed in all the 
best and wisest economy which, in the long run, shall best effect the desired 
object. 

" The chief points of excellence are extensive, well laid-out, and carefully- 
planted airing-courts and pleasure-grounds, and sufficiency of cultivated land 
for out-of-door employment ; spacious, airy, and well ventilated apartments ; 
the extensive application of steam to every available purpose, cooking, pump- 
ing, heating, ventilating, &c., and open fireplaces in every admissible room. 
The most important of all are the extensive arrangements made for the manual 
employment of the inmates both within doors and without. There are work- 
shops for the different trades, in some of which these trades had been success- 
fully taught, and in many the amount of work performed showed that the shops 
were sources of profit to the institution, as well as of beneficial employment to 
the patients. 

" Another feature which struck me most pleasantly was the construction, in 
several hospitals, of a large and handsome room, especially for the social 
gatherings and amusements of the patients. My attendance at some of these 
festival occasions is among the most pleasant reminiscences of my visit. A 
large amount of profitable out-of-door labour is insisted upon in many, and the 
amount accomplished in some instances is highly creditable. It is very evi- 
dent that, if the American institutions are to maintain the comparatively high 
rank to which they have justly heretofore had claim, a more liberal expendi- 
ture than has been adopted in most, in regard to occupation both of body and 
mind, amusement, &c., must be adopted." 

4. The movement of the population of the Lunatic Asylum for the Poor of 
New York City, for 1853, as given in the report by Dr. Ranney, was as follows: 

Number of patients January 1st 
Admitted in course of the year 

Whole number 

Discharged, including deaths 
Remaining Dec. 31, 1853 . 
Of those discharged, there were cured 
Died 



Men. 


Women. 


Total. 


226 


301 


527 


226 


261 


487 


452 


562 


1,014 


220 


252 


472 


232 


310 


542 






271 


56 


59 


115 



Of those cured 14 were cases of delirium tremens, 2 of febrile delirium, and 7 
who were discharged, "recovered," twice each, in course of the year. These 
being subtracted, the number of cures is 248. 

*' The ratio of recoveries," remarks Dr. Ranney, " is a little more than 50 
per cent. The proportion must depend much upon the length of time the dis- 
ease has existed previous to admission. Usually, the indigent are placed in an 
asylum earlier than the wealthy. For this, as well as other reasons, the per- 
centage of recoveries in a hospital of this character should be larger than in 
institutions devoted to the use of the higher classes, provided the means for 
effective treatment be furnished." 

Causes of death. — Consumption 45, chronic diarrhoea 14, paralysie e6nerale 
No. LIX.— July 1855. 10 



142 



BihliograpTiical Notices. 



[July 



13, congestion of the brain 7, marasmus 6, typhus fever 4, typho-mania 4, para- 
lysis 3, apoplexy 3, dysentery 3, delirium tremens 2, epilepsy 2, chronic pleu- 
risy 2, dropsy 2, suicide 1, accidental drowning 1, pericarditis 1, haemoptysis 
1, inflammation of spinal marrow 1. 

" It will be seen that consumption is the most common (cause of death). 
The prominent symptoms of this disease are usually absent where insanity 
exists. The patient will frequently walk until near the day of his death, and, 
if there be any cough, it is often so slight as to escape observation." 

Of 3,160 patients who have been received since January 1,1847, no less than 
2,381 were foreigners, and but 779 native Americans. The largest number of 
natives received in any year was 149, in 1847 ; the smallest number, 94, in 
1853. Of foreigners, the number has increased from 280 in 1847, to 393 in 
1853. This is accounted for by the increase of immigration. The leading 
numbers in the table of nativity for 1853 are as follows: Ireland 241, Ger- 
many 94, England 19, Scotland 10, Switzerland 5, France 4. 

" Very few of the indigent insane of this city are sent to the State Asylum 
at Utica, and none to Flushing, Hudson, or the Bloomingdale Asylum. Either 
the ratio of insane is very much less among the natives, or they are kept at 
their homes. Probably the first supposition is true, and this may arise in part 
from peculiar causes incident to emigration, and in part from the shipment of 
the insane from Europe during a lucid interval." 

Dr. Eanney, as he intimates, has had uncommon advantages for studying 
chronic dementia, and he asserts his belief that " by constant training, very 
many who, if left to themselves, fall into the most miserable condition, would 
become valuable aids in the asylum, even if perfect recovery did not follow. * 
^ * If there were an important organic lesion of the brain, no great im- 
provement could be expected ; but, from my examination of this organ in a 
great number of cases, the proportion in which important lesions were found has 
not been large. The enfeeblement of the mind depends, in many cases, upon the 
loss of tone, from inaction. ^ ^ * After some acute disease has existed, as 
mania, this organ becomes exhausted, i. e. loses its tone, and can only be restored 
by nourishment and the proper mental stimulus J' 

These remarks remind us of the case of a man of more than ordinary intel- 
lectual capacity, who was more than fifteen years a patient at Bloomingdale, 
a large part of the time demented. Attacked with typhoid fever, and removed 
to the New York Hospital, he died. The late Dr. Swett made a post-mortem 
examination, and found, in the brain, no lesion of importance — absolutely 
nothing whereby to explain the patient's long-continued mental incapacity. 

5. In their report for 1853, the Commissioners of the Indiana Hospital for the 
Insane refer to the resignation of Dr. R. J. Paterson, who had held the office 
of superintendent from the opening of the institution, and remark that '* in his 
departure he carried with him not only the high esteem of every other officer 
and attendant of the hospital, but, we trust, of every friend of the unfortunate 
lunatic in the State." He left on the 1st of June, 1853, and was succeeded by 
Dr. James S. Athon. 

Men. Women. Total. 



Patients in the hospital October 31, 1852 . . 81 78 159 

Admitted in course of the year ... 74 82 156 

Whole number 155 160 315 

Discharged, including deaths .... 77 75 152 

Remaining October 31, 1853 .... 78 85 163 

Of those discharged, there were cured . . 47 39 86 

Died 7 7 14 



*' While portions of our country have suffered from disease, the Hospital for 
the Insane has escaped everything like an epidemic. This immunity from in- 
termittents, remittents, and dysenteries, may be attributed to the favourable 
location of the institution, and to the prompt and rigid enforcement of the 
sanitary laws for the government of the establishment." 



1855.] 



American Insane Hospital Reports. 



143 



"Already over two hundred insane are knocking at the door of the hospital 
for admission, and cannot be received for want of room. The institution is 
crowded to its utmost capacity." The erection of an additional wing is in 
prospect. 

Two suicides, the first which have occurred in the hospital, took place in the 
course of the year. 

From the remarks by Dr. Athon upon the medical treatment of the insane, 
we make the following extract : — 

"Emetics and purgatives are useful in expelling vitiated matters from the 
stomach and bowels. Conjoined with proper diet and exercise, they may be 
made subservient in restoring the natural secretions of the alimentary canal. 
To attempt to make a lasting and beneficial impression on the system by re- 
peating these remedies beyond their aperient or gently evacuant effect, is irra- 
tional and highly injurious to the patient. There are too many cases brought 
to this hospital, exhausted to mere skeletons by the use of the lancet, blisters, 
and purgatives, to deny, for one moment, this position. By the administration 
of tonics, and the use of a nutritious diet, a large proportion are restored to 
physical health. These remarks are made with the hope that our professional 
brethren who may have charge of patients before sent to the hospital, will keep 
in view that the hypercynosis system can very rarely, if at all, do good in cases 
of insanity." 

We now come to the report for 1854 : — 

Men. Women. Total. 

Patients in the hospital October 31, 1853 . 78 85 163 

Admitted in course of the year 

Whole number 

Discharged, including deaths 
Remaining October 31, 1854 
Of those discharged, there were cured 
Died . . . . 



83 86 169 

161 171 332 

88 84 172 

73 87 160 

59 55 114 

5 8 13 



Causes of death. — Typho-mania 3, general paralysis 2, maniacal exhaustion 
2, pulmonary consumption 2, scrofula 2, tabes mesenterica 1, erysipelas 1. 

*' Scarcely any other disease," remarks Dr. Athon, " than what is conse- 
quent to insanity, has had a place in our wards, although the adjacent country 
has suffered much from summer and autumnal afflictions." 

It is stated in the report of the commissioners that the great percentage of 
cures "is, in part, attributable to the selection of patients, receiving those whose 
insanity is of the most recent date — not filling up the hospital with chronic 
cases that are hopelessly incurable." 

Two festivals were enjoyed by the patients in the course of the year. On 
May-day " a banquet was given, and the day celebrated with as much parade 
as is usually manifested upon such an occasion ;" and " the second annual 
celebration, at the hospital, of American independence, was attended, like the 
first, with the happiest results. Above a hundred patients participated in the 
festivities of the occasion." 

Men. Women. Total. 

Patients admitted from Nov. 1, 1849, to Oct. 31, 

1854 372 367 739 

Discharged, recovered 192 178 370 

Died 63 

Religious excitement and anxieties is alleged as the cause of the mental 
alienation in 61 cases, Millerism in 2, and " spiritual rappings" in 29. 

" Millerism, in its day," says Dr. Athon, " startled the minds of men and 
turned them into religious bigots, and thence the transition was easy, in many 
instances, to insanity. But the spiritual rapping mania eclipses Millerism, or 
any other ism, in its agency to produce aberration of mind. The spiritualists 
professs to commune with departed spirits, and through their omniscience learn 
the condition of the dead, look into the future, and do other ridiculous things. 



144 



BibliogropMcal Notices. 



[July 



This delusion prevails, in some parts of tlie country, to a most unaccountable 
extent, and has been prolific, beyond any other one cause, of insanity/' 

6. The reports from the Illinois State Hospital for the Insane are biennial, 
that which is about to occupy our attention being for the fiscal years ending on 
the 30th of November, 1853 and 1854. 

The former superintendent having left the institution, he was succeeded, in 
June, 1854, by Dr. Andrew McFarland, for some years favourably known to 
our readers as the principal officer of the State Asylum of New Hampshire. 
The Trustees remark of him that their high expectations in regard to his supe- 
rior qualifications for the office " have been fully realized.'' 

Patients in the asylum Dec. 1, 1852 ... 82 

Admitted in the two years 265 

Whole number 347 

Discharged, including deaths .... 181 

Kemaining Dec. 1, 1851 166 

As the hospital affords accommodation for the two sexes equally, and the 
whole has been occupied the most of the time recently, the number of males 
and females has been nearly the same." 

Of the patients discharged, there were cured . 114 
Died 21 

" The bodily health of the inmates of the hospital has generally been good. 
No epidemic has at any time prevailed, although during the past summer 
(1854) the danger seemed somewhat imminent from the frequency of cases of 
cholera in the vicinity. The instances of mortality have mainly occurred 
among those exhausted by long-continued mental disease. The fact cannot be 
questioned that most forms of mental disease shorten the period of human life. 
In the exceptions to the rule, in all cases of high excitement, it will be found 
that lucid intervals occur which allow nature to recover itself before the point 
of exhaustion is reached. 

" Epilepsy, palsy, and consumption will annually claim a class of victims in 
whose temperament certain predispositions exist. But the natural termina- 
tion of mania, as it usually occurs, is in a form of disease which has eluded the 
nomenclature of medical writers. It consists in the failure, seriatim, of those 
physical functions whose healthy performance depends upon a normal inner- 
vation. [What functions do not require normal innervation for normal per- 
formance?] The hesitating step and a difficulty of utterance are anaoug the 
earliest indications that the brain is losing its supremacy. Calorification faiU ; 
the extremities become cold, and the individual is found hovering about the 
registers or other sources of artificial heat. Soon the circulation becomes en- 
feebled ; the face assumes a swollen and stolid appearance ; the extremities 
swell and become purple, especially if in a dependent position. Digestion be- 
comes involved, and emaciation quickly follows. The legs break out with 
ulcers which soon become the nucleus of extensive sphacelation, and death is 
welcomed to close the scene. The individual usually sinks before all the stages 
in this succession of physical decay have been taken. Science has given no 
name to this disease, whose aspect is familiar to all who treat the associated 
insane. It is neither palsy, dropsy, nor marasmus, and yet it combines some- 
thing of each." 

Of the 406 patients who have been received at the institution since it was 
opened, on the 3d of November, 1851, onli/ forty-six were natives of Illinois. 
The others, so far as known, were immigrants from various States and coun- 
tries, in the following proportions : New York 47, Kentucky 36, Pennsylvania 
35, Ohio 25, Indiana 16, Tennessee 15, N. Carolina 13, Virginia 11, Vermont 7, 
N. Hampshire 7, N. Jersey 7, Massachusetts 5, Maryland 5, Connecticut 4, 
Maine 3, Delaware 3, Missouri 2, R. Island 1, Wisconsin 1, Georgia 1. Ger- 
many 30, Ireland 25, England 12, Scotland 4, France 3, Sweden 1, Ptussia 1, 
Poland 1. 



1855.] 



American Insane Hospital Rejports. 



145 



Dr. McFarland thinks that, considering the great proportion of foreigners 
among the inhabitants of the State, the number of them in the hospital is small, 
*' The Germans/' he observes, " are the best, as they are the most numerous, 
of our foreign patients. They possess a healthy and elastic mental constitu- 
tion ; they are docile and affectionate under treatment, and grateful when they 
recover." • 

We know that for many years there has been some discrepancy of opinion 
among the superintending physicians of our institutions for the insane, in re- 
gard to the utility of a committee such as is mentioned in the subjoined ex- 
tract ; and we rejoice that Dr. JM. has found it to Avork so favourably : — 

" Another feature in the experience of the hospital for the past year, too 
interesting and too important to be passed without notice, is the formation, on 
the part of the ladies of Jacksonville, of a benevolent association, having for its 
express object a regular and stated visit to the institution on the Saturday of 
each week, by a committee assigned in rotation. This society, appropriately 
styled ' The Dix Association,^ we regard as a conception of the most happy 
kind, and its operations have been peculiarly promotive of the welfare and 
happiness of the unfortunate persons for whose benefit it was instituted. We 
earnestly hope that the zeal and faith of the society may be sustained, fully 
believing that its formation is an important era in the history of the institu- 
tion.'' 

The original plan of the buildings of the hospital at Jacksonville consisted 
of a central building and four wings, with accommodations for about four 
hundred patients. But two of the wings have been erected. These furnish 
apartments for but 168 patients, and the hospital is so much crowded that 
parlors are being converted into dormitories, undoubtedly to the detriment of 
the establishment. The question now is, whether the primary design shall be 
carried out, or a new hospital established in another portion of the State. The 
Association of Physicians to American Institutions for the Insane have depre- 
cated hospitals intended for more than 2-50 patients, yet Dr. McFarland advo- 
cates the enlargement of that at Jacksonville, by the addition of the formerly 
contemplated wings, and alleges the reasons therefor, expressing his belief that 
the special circumstances render this institution an exception to the general 
rule. 

7. The second biennial report of the Trustees and Superintendent of the 
Missouri State Lunatic Asylum, is the first which has reached us from that 
institution. We have no information in regard to the precise time at which 
the establishment was opened, nor any detailed description of it. It appears 
that it contains seventy-two rooms, each designed for one patient; that it is 
being enlarged, so as to accommodate about seventy more; and that it is under 
the superintendence of Dr. T. R. H. Smith. During most of the period em- 
braced by this report it has been over-crowded with patients, the " usual ave- 
rage" number having been " about one hundred and over seventy applica- 
tions for admission have been rejected. 



Patients in the Asylum Nov. 29, 1852 
Admitted in the course of two years . 

Whole number 

Discharged, including deaths 
Kemaining Nov. 27, 1854 . 
Of those discharged, there were cured 
Died 



Men. Women. Total. 



34 


28 


62 


68 


55 


123 


102 


83 


185 


49 


42 


91 


53 


41 


94 


20 


23 


43 


22 


16 


38 



Causes of deatli. — Epilepsy 11, consumption 6, chronic diarrhoea 4, typhoid 
fever 4, " ulceration of bowels" 3, paralysis 2, " disease of heart" 2, inflamma- 
tion of bowels 2, ascites 1, accidental burn 1, abcesses and gangrenous ulcers 
at time of admission" 1, exhaustion 1. 

" The general health of our household has been very good, excepting during 
the past season (1854). The intensely warm weather which continued during 



146 



BihliograpMcal Notices. 



[July 



the summer months, in connection with the unparalleled drouth, produced an 
unusual amount of sickness among our patients. The citizens of Fulton, 
whose healthfulness, heretofore, has been proverbial throughout the State, also 
suffered greatly from dysentery. The prevailing disease with us was diar- 
rhoea, with a few cases of dysentery and typhoid fever. The attacks were 
generally very violent in their character, and all of a typhoid tji'pe. The 
fatality, the number of cases considered, could not be regarded otherwise than 
small.'^ 

Dr. Smith, in explaining the apparently, the really large mortality, says : 
" The patients received into this institution, when first opened, and until filled 
to its entire capacity, with a few exceptions, were those of long standing, who 
had been accumulating for many years in consequence of the want of provi- 
sion for their proper treatment. A large number of these were also labouring 
under incurable diseases associated with their insanity." Such, or similar, 
has been the experience at a very considerable number of our institutions, and 
Dr. Smith is not the first who, at the opening of an asylum, has seen a large 
number of his patients succumb within the first few months. 

Of the epileptics, " the majority died during convulsions, and the remainder 
gradually sunk under the exhausting influence of repeated attacks." The 
death from "accidental burn," was that of Theodore McGready, " an idiotic boy, 
admitted in accordance with a special act of the last Legislature. * * * 
A few weeks before the accident, the weather becoming cold, and in conse- 
quence of the unfinished condition of our steam heating apparatus, we were 
forced to take all our patients from the halls into the stove-rooms in the centre 
building, to prevent them from suffering. * ^ ^ Early in the morning of 
the day of this sad occurrence, the attendant took Theodore into the stove-room 
first, and returned for other patients, expecting to be absent only a minute or 
two. After reaching the hall, he heard him crying, ran immediately to the 
room, and, upon entering, to his great astonishment, found his clothes on fire. 
He made every effort to extinguish it, but before it could be done the burn was 
very severe, extending over his abdomen, his sides, between the lower extremi- 
ties, the forearms, and hands. * * * He received every attention in our 
power, through the day and night, b)ut the constitutional irritation was so great 
that he died the next morning, about twenty hours after receiving the burn. * 
•3«- * * * ^jl^e manner in which our building is now heated (by steam) 
precludes the possibility of another such accident." 

Whole number of patients since opening of Asylum . 193 

Married 81, single 100, widows 9, widowers 3 . . . 193 

Insanity commenced between 20 and 30 years of age in 81 ; between 30 and 
and 40 in 51. Among the assigned causes of the insanity of the patients are: 
Miasmatic fevers 25, spiritual rappings 4. 

The moral treatment pursued at this asylum is similar to that of other Ame- 
rican institutions of the kind, and is already so fully understood as to require 
no further description in this place. A chapel has been constructed, and a 
library of 500 volumes collected by gratuitous contribution. 

In his discussion of the causes of mental disorders, Dr. Smith makes the 
following observations : — 

It has been a source of astonishment to many that insanity should prevail 
to so great an extent in this highly favoured land of ours, and seems to be 
increasing even in a greater ratio than our population, and is, perhaps, of more 
frequent occurrence in this than in most other countries of the world. The 
general impression is that our happy form of government * * -x- would be 
incompatible with its prevalence, at least to any great extent. It is true, the 
elements which enter into the composition of our government, in the abstract, 
seem well calculated to contribute to man's highest and best interests ; yet the 
freedom of thought and action possessed by every individual connected with 
this highly-favoured state of things, the high degree of excitement incident to 
the different pursuits of life; the spirit of emulation ; the hopes, the fears, the 
joys, the sorrows brought into exercise in quick succession — all tend, in a 



1855.] Gross, Diseases, etc., of the Urinary Bladder , etc. 



147 



striking manner, to disturb the equilibrium so essential to the healthy action 
of the mental faculties ; and, by a repetition of the same excesses of feeling, 
this governing and protecting principle is lost, disease developed, and the mind 
in ruins one of the sad and fearful results. Is not the conclusion, therefore, 
justifiable that our form of government, with the habits of our people, is calcu- 
lated to increase rather than diminish the frequency of insanity, especially 
when we reflect that the causes referred to are acting upon ill-balanced minds 
and misproportioned characters, the effects of inefiiciency of the intellectual and 
moral powers with those not favoured with good opportunities in early life, and 
their misdirection with those who enjoyed better advantages. 

" The great practical question, then, is, What must be done in this, our 
happy country, already the hope and admiration of the world, to prevent, in 
the midst of so many exciting causes, the most terrible of all afflictions ? The 
answer is, ample provision for, and a radical reform in, the early education of 
the rising generation ; or, in other words, the more careful and philosophical 
cultivation of the intellectual and moral faculties and propensities of all, in 
harmony with a correct physical education. Inefficient and misdirected early 
education constitutes the great predisposing cause to crime as well as insanity ; 
sad combination, truly. The statistics of all hospitals for the insane prove that 
the great majority of the cases of insanity occur between the ages of fifteen and 
thirty, and the statistics of crime give us nearly the same results." 

We are but little disposed to differ from our friend. Dr. Smith, in the really 
essential parts of this extract ; but we must venture to propose some of the 
thoughts suggested by the perusal of it. The island of Malta was, by nature, 
a single mass of rock, almost wholly destitute of vegetation and of soil. Yet 
the Maltese boasts of his home as " The flower of the world." The Neapolitan 
exclaims, " See Naples, and die V (there being nothing more beautiful to be 
seen.) They of the country of Confucius, who claim that theirs is the " Celes- 
tial Empire," say, " We have two eyes, the Europeans have one, and all the 
other inhabitants of the world are blind." We smile at the simplicity of the 
Maltese, we do not esteem Naples so much of a paradise as to be willing to die 
the moment we have seen it, and our people are not so much enamoured with 
the ocular advantages of the Chinese as to prevent a disposition to expel them 
from the country. Now let the impartial statesman, or jurist, or philanthro- 
pist, read the first of the two paragraphs quoted, and would he be so thoroughly 
convinced of our happiness, as a people, that, in the fulness of his heart, he 
would reiterate our expression to that effect, almost at the very beginning of 
the second ? or would he rather pause to reflect whether, after all, we are so 
truly happy as we claim to be ? We will not anticipate the decision of the 
question ; for, most certainly, if we are not a people among the happiest in the 
. world, it is not in default of as great a proportion of the means or elements of 
happiness as has ever fallen to the lot of any nation. Do we employ those 
means wisely ? Do we combine those elements with the skill which is sug- 
gested and produced by a profound and just philosophy? Lord Morpeth, now 
the Earl of Carlisle, after his tour through the United States, declared it as his 
opinion that no other people on earth possess so many of the comforts of life as 
the Americans, and among none is there so little happiness. P. E. 



Art. Xyil. — A Practical Treatise on the Diseases, Injuries, and Malformations 
of the Urinary Bladder, the Prostate Gland, and the Urethra. By S. D. Gross, 
M. D., Prof, of Surgery in the University of Louisville, &c. &c. &c. Second 
edition, revised and much enlarged, with one hundred and eighty-four illus- 
trations. Philadelphia, Blanchard & Lea, 1855. Pp. 925, including Appen- 
dix and Index. 

The appearance, within four years, of a second edition of this admirable 
work, sufficiently proves that, notwithstanding its bulk and elaborate character, 



148 



Bihliogra][ihical Notices. 



[July 



a monograph of the kind was wanted and has been properly appreciated by the 
medical profession. 

As the first edition was reviewed at length soon after publication (see No. 
of this Journal for October, 1851, p. 415, et seq.), it will answer our purpose 
on this occasion merely to call attention to some of the additions and other im- 
provements of the present issue. 

The whole work has been thoroughly revised, and thus rendered, as its inde- 
fatigable author justly hopes, still more worthy of the patronage and confidence 
of his medical brethren. His '* object has been to afford at least satisfactory, 
if not full, information upon every subject treated of in its pages a task 
which he has found it impossible to accomplish in a smaller compass than that 
of the unusually thick octavo volume in which he has presented the results of 
his extended observations and researches. Large as it is, however, it is entirely 
too ample in its scope and rich in practical detail, as well as too concise in style, 
to be regarded with apprehension by the genuine student. No intelligent 
reader can estimate our author's book as anything but a great good instead of 
a great evil, however unwieldy in dimensions, while it continues to embrace so 
little that the earnest inquirer could afford to lose, and so much to instruct 
and interest every one who may refer to its clear and comprehensive exposi- 
tions. 

Two hundred pages and seventy-eight illustrations have been added in the 
present volume. These additions " are dispersed through the work in the form 
of new paragraphs, sections, and chapters, which impart to it somewhat of the 
aspect of a new treatise.'' 

We have taken a good deal of trouble, in looking over the new edition, to 
compare it with the old, for the purpose of briefly noting the principal changes 
which impressed us as most worthy of attention. But the alterations are so 
numerous and important, and are distributed to such an extent throughout the 
work, that the attempt to point out even a small portion of them would involve 
us in a lengthened review, which at this time would be out of place. 

It will suffice to say that Prof. Gross appears, if possible, to have exhausted 
his theme, at least so far as principles and their general applications are con- 
cerned ; and that he has missed no opportunity, that we can discover, to bring 
his treatise completely to the level of the present state of progress in respect to 
everything which he has undertaken to discuss. 

Perhaps the most important feature of the new edition, which distinguishes 
it from its predecessor, is an extremely interesting appendix of some twenty- 
nine closely printed pages, occupied with a statistical inquiry into the preva- 
lence and etiology of urinary calculi and calculous disorders in the United 
States and Canada. This is believed by the author to be "the first attempt 
that has ever been made to collect and systematize our information upon that 
subject." 

" The facts," says Dr. Gross, "which form the basis of this division of the 
subject have been collected with great care, and comprise, it is believed, an 
accurate outline of our knowledge upon the subject. However this may be, it 
is hoped that they will not be without value, and that they will have the effect 
of awakening further and more extended inquiry into the locality and etiology 
of a class of affections of so much interest and importance.'^ We are strongly 
tempted to lay before our readers some of the most curious of the statements 
which embody the results of this investigation, but we must perforce content 
ourselves with recommending them, as well as all the other matters so attract- 
ively dwelt upon and illustrated in the different chapters, to the serious atten- 
tion of every medical practitioner who has truly at heart his own best interests, 
as well as those of his patients, to say nothing of his calling. 

"When it is recollected," remarks Dr. Gross, in relation to the topics of his 
work, " that these affections are of daily occurrence in every community, that 
they entail a vast amount of suffering, and that they are a frequent source of 
mortality, it is surprising, nay, positively shocking, to find how much they are 
neglected by systematic writers and public teachers." We most cordially 
sympathize with him, in the hope that his contribution, "in its present im- 
proved form, will have the effect of arousing the attention of the profession to 



1S55.] 



Ha J ward; Surgical Reports. 



149 



a mare full and just appreciation of the important and interesting affections of 
which it treats, and of elerating them, in their estimation, to the same rank as 
the maladies of the eye, ear, and other organs, concerning which so much has 
been published in the Tarious languages of Europe." E, H. 



Art. XYIII. — Surgical Beporis and Miscellanemis Papers on Medical Subjects. 
By George Hatward, M. D., President of the Massachusetts Medical So- 
ciety ; Fellow of the American Academy of Arts and Sciences ; late Pro- 
fessor of Surgery in Harvard Uniyersity ; and Consulting Surgeon to the 
Massachusetts General Hospital. Boston: Phillips, Sampson, & Co. 1855. 
12mo. pp. 452, including index. 

Our readers will recognize, in the neat volume with the above unpretending 
title, a number of old acquaintances, which they will be glad to meet again in 
a more permanent and accessible form. Nearly all the papers of which it is 
composed have been already published in some shape or other, many of them 
having made their first appearance in this Journal, while most of the remainder 
have been noticed in our pages. " They are now collected," according to their 
author, " from a belief that some of them would be useful from the facts and 
tables they contain, and in the hope that all might be read with advantage by 
students and the younger members of the profession. It was even thought 
that they would perhaps be occasionally consulted by those somewhat advanced 
in practice, whose time was too much occupied to allow an examination of 
more extended works on the subject of which they treat." 

JSio one who is at all familiar with the personal and professional character of 
Dr. Hayward and his writings, can hesitate to admit that he has conferred a 
great favour on his medical brethren, in thus presenting a revised and uniform 
edition of his previously scattered contributions. 

These various essays are especially interesting as the memorials of a well- 
spent and unusually honoured professional career of nearly half a century^s 
duration. They are still more valuable, however, for their intrinsic merits as 
the legitimate fruits of the practical good sense and extended reading and 
experience which so eminently distinguish their veteran and able author, 
whether as a teacher or practitioner. 

The first eighty pages are occupied with an instructive series of clinical reports 
and comments on surgery and surgical operations in the Massachusetts General 
Hospital. Then we have an important report on the " Permanent Cure of 
Reducible Hernia." This paper is particularly deserving of attention, on ac- 
count of its conclusions. They accord so entirely with the views which a good 
deal of special inquiry as well as positive experience have impressed upon us, 
that we are glad to reproduce them here. 

1. That there is no surgical operation at present known, which can be 
relied on, with confidence, to produce in all instances, or even in a large pro- 
portion of cases, a radical cure of reducible hernia." 

"2. That they regard the operation of injection lay the subcutaneous method 
as the safest and the best. This will probably, in some cases, produce a per- 
manent cure, and in many others will afford great relief." 

" 3. That compression, when properly employed, is, in the present state of our 
knowledge, the most likely means of effecting a radical cure in the greatest 
number of cases." — Pp. 116, 117. 

After this comes a succession of chapters on different subjects, all of more 
or less interest to the professional inquirer, and some of them of a nature to 
command the attention of the general reader. Among them, those which 
struck us as perhaps most worthy of note, were the well known Statistics of 
Amputations, the article on Yesico-Yaginal Fistula, those on Anaesthetic Agents, 
on Statistics of Consumption, and on the Contagion of Cholera. We shall not 
proceed with our selections, because a farther perusal of the book only adds to 
the difficulty of choice, whilst it tempts us largely to extend our list. 



150 



Bihliogra-pliicaJ Xbtices. 



[July 



This is not the time or the place for a discussion of the only question broached 
in relation to the Statistics of Consumption, which is the comparative mortality 
from that disease, in the cities of Boston, Xew York, and Philadelphia. It is 
too serious and diScul!: a topic to be touched upon in the only manner within 
the compass of a ^ ns jinz notice. Still, we may venture to suggest one matter of 
consideration, as likely lo have a decided effect upon the relative proportions of 
fatal or.^es. r/.though it does not appear to have entered into Dr. Hayward's cal- 
culations. IIoTT far it ought to be considered, we are not prepared to show; but 
we are satisfied that it should not be forgotten. "We refer to the fact that 
numbers of phthisis patients annually leave Boston and Xew York for more 
favourable climates aud localities; and that many of these unfortunates not 
only withdraw themselves permanently from their original homes, but remain 
tD live or die in Philadelphia. For the same reason, but to a more limited 
extent, Philadelphia, of course, annually parts with her share of invalids, who 
go to increase the burthen of mortality in districts farther south. 

We are glad to find that, up to the present day, Dr. Hayward, one of the 
first and most infiuential pioneers of antesthesia, continues an advocate of the 
use of pure s-uIvJiirrlc etJier, in preference to all other known pain-suppressing 
agents : whilst he uncompromisingly condemns the resort to chloroform in any 
of its combinations, and especially in the delusive mixture which has been em- 
ployed as chloric ether. One of the latest authorities in behalf of chloroform — 
and per'_oy - ir.e c f the best as to expertness, experience, and entire immunity 
from fatal misohief in its use — is Mr. Syme, of Edinburgh. This sagacious 
but rather eccentric operator tells his pupils, in a recent clinical lecture, that 
the better fortune of himself and colleagues, in the employment of this potent 
instrument, is due to a mire rational mode of administration of it.^ That they 
give it according to principle,"'' and not "according to rule ;'^ that there are 
"considerable differences between our practice and that which prevails more 
or less elsewhere,^' and that in this he is only following the example of the 
discoverer, Dr. Simrson, 'London Lancet for 1855, p. 200.) "We must refer to 
the lecture itself f.r the various and doubtless excellent instructions given with 
regard to the points to be observed in carrying out the plan he recommends. 
TTe would feel much more at ease, however, if, in preparing a patient for ope- 
ration, we could produce a sufBciently analogous result without the necessity of 
so many minute precautions in order to preserve our patient from constantly 
impending sudden death. We take leave of our most excellent friend and col- 
laborator with the best wishes for his long continued health and prosperity. 
We heartily commend his little book to all our readers, and sincerely entertain 
the hope that we may yet enjoy the benefit of his instructions on the many 
other topics, still untouched, which he is so well fitted to discuss. E. H. 



Art. XIX. — Dimcidt LoLjOurs and tlieir Treatnieni. By M. B. Weight, M. D,, 
of Cincinnati. For which a Gold Medal was awarded by the Ohio State 
Medical Society. 8vo. pp. 32. 

ly this essay Dr. Wright confines himself exclusively to a consideration of 
the proper management of that form of difficult labour in which there is a pre- 
sentation of one or other of the shoulders of the foetus at the brim of the pelvis. 

Although it is possible, in these cases, for delivery to be effected by the un- 
aided efforts of the uterus, still, in the great majority of instances, the safety of 
both mother and child requires a resort to manual interference at as early a 
period as possible after the malposition of the foetus has been detected. 

By the leading authorities in obstetrics of Great Britain, and Continental 
Europe, as well as of this country, it is taught that the proper management of 
these cases is to bring down the feet at once, while the uterus is in the most 
favourable condition to enable us thus to turn the foetus; bat when, from any 



1855.] 



Wright, Difficult Lahours and their Treatment. 



151 



circumstance, this cannot be accomplished, vre are directed to open the chest of 
the child, remove the viscera, and extract by the crotchet. 

The attempt to bring down the head in a favourable position in cases of 
shoulder-presentations has, at the present day, but few advocates, excepting, 
perhaps, in certain exceptionable cases of very rare occurrence. 

In the essay before us, Dr. Wright has endeavoured to prove that cephalic 
version, as it has been termed — the changing of a shoulder into a favourable 
vertex presentation, while it is a preferable procedure to turning by the feet, is 
applicable to a much larger number of cases than is generally supposed : the 
opposition to it, on the part of the leading obstetricians of the present day, 
originating in the improper manner by which it has been attempted to be accom- 
plished, rather than in any difl&culty or danger attendant upon the operation 
when properly conducted. 

After referring to a few cases in which the head was very promptly substi- 
tuted for the shoulder as the presenting part. Dr. Wright considers himself jus- 
tified in declaring — 

" 1. That at an early period in labour, and especially if called before the uterus 
has been deprived of its liciuid contents, a shoulder may be converted into 
a vertex presentation more easily than turning by the feet is ordinarily per- 
formed. 

" 2. That although the membranes may have been long ruptured, turning by 
the head can be accomplished with great facility. 

" 3. That delivery by cephalic version may be speedily effected, after repeated 
and ineffectual efforts have been made to turn by the feet. 

"4. That cephalic version should receive a prominent, nay, leading place, as 
a means of expediting delivery in shoulder-presentations." 

In regard to the question as to which mode of procedure, turning by the feet 
or cephalic version, will prove most favourable to the mother, after noticing the 
disadvantages of podalic version as pointed out by Churchill ; namely, the fear- 
ful risk incurred of injury to the mother, in consequence of the distance the 
head has to traverse, and the difficulty of seizing the feet, and of turning the 
child in utero ; after pointing out the fact, as shown by the tables prepared by 
Dr. Lee, that out of seventy-one cases of shoulder-presentations, in which turn- 
ing by the feet was resorted to, " seven women died from rupture, and three 
from inflammation:" three of the cases of rupture occurring in patients under 
the care of Dr. Lee, where no great difficulty was experienced or force employed 
in turning. Dr. Wright remarks, that — 

" In cephalic version the hand does not enter the cavity of the uterus, and, 
consequently, neither its walls, nor any portion of them, are forcibly pushed 
out. the foetus is moved comparatively little within the uterus, the head being 
already near the superior strait ; while in p)odalic version, the part to be first 
delivered, is most remote from the canal through which it must pass. In the 
former, the injury to the mother cannot result without great awkwardness on 
the part of the obstetrician, while in the other we have reason to feel surprised 
at the escape from injury. In turning by the feet, the hand must necessarily 
be moved considerably within the uterus, and often while it is contracting vio- 
lently. In turning by the head there is but little, if any, direct contact of the 
hand within the uterus. In the one case, contusion of the uterus by the hand 
is to be expected ; in the other case, there is no injury, because there is no con- 
tact. Turning by the feet may occasion a severe nervous shock. ISTot so chang- 
ing the shoulder for the head." 

Dr. Wright examines next the influence of the two modes of procedure upon 
the life of the child. 

" In describing," he remarks, " the disadvantages of turning by the feet in 
all cases, Churchill says: 'The mortality amongst the infants thus brought 
into the world is very great. As far as our statistics extend, they yield 174, 
out of 518 delivered, or 1 in 3.' 

" The mortality in shoulder-presentations is, doubtless, greater than this. In 
the first place, the position of the foetus weakens its hold upon life. In the 
second place, the hand is more difficult of introduction into the uterus in 
shoulder than in head-presentations, and whatever force is required is sensibly 



152 



Bibliographical Notices. 



[July 



felt by the foetus, and upon that part of the body Trhere pressure is made with 
least impunity. 

A timely resort to cephalic version gives to the foetus almost as much cer- 
tainty of life as if the presentation had been originally of the head. Why not? 
The manoeuvre amounts to but little more than in rectification of deviated head 
positions. 

" We are informed by Churchill, that, ' Bush gave an account in 1826, of 
fifteen cases, in v^hich fowieen -vrere born living. In 1827, Ritgen collected 
forty-five successful cases. Riecke has had sixteen cases.-' In all the cases 
treated by myself from the beginning, the children were born alive. The 
liability to compression of the chord and consequent death of the foetus, is in 
proportion to the length of the labour, or rather to the descent of the foetus in 
the cavity of the pelvis. Hence, to be wholly successful, cephalic version should 
be performed a short time before, or soon after the commencement of the second 
stage of labour.^^ 

To the question, can any one mode of treating shoulder-presentations be relied 
on exclusively ? Dr. Wright replies in the negative. 

" We are disposed," he says, " to adopt the language of Cazeaux, ' that at the 
present day it would be improper to embrace either practice exclusively ; some 
cases are better suited to cephalic version, while there are others, on the other 
hand, where pelvic version is alone practicable ; consequently both operations 
should be retained in practice, leaving the judgment of the accoucheur to deter- 
mine the cases where the one or the other should be preferred.' 

*' Turning by the feet,'' according to Dr. Wright, "is to be preferred in cases 
of inefficient uterine action, or in exhaustion from long continuance of labour; 
in hemorrhage, convulsions, or in any case in which there may be a demand for 
speedy delivery. 

" Turning by the head should be selected in all cases where difl&culty arises 
from mal-position merely ; or in convulsions, hemorrhage, or prolapsus of the 
funis, if the uterus should be engaged in vigorous expulsive efforts. In rup- 
ture of the uterus our great reliance is in artificial delivery ; and the question 
naturally suggested would be, which would guarantee the greatest safety, 
podaiic version, or cephalic version, aided by the forceps ? And we should be 
guided in our action by the answer we give to the question," 

Dr. Wright, of course, lays no claim to the introduction of cephalic version 
as a mode of treating wrong presentations, and expediting delivery; he thinks, 
however, that the credit of originality may be awarded to him in respect to the 
means he has suggested for efi'ecting readily and successfully, a change of 
shoulder-presentations into a favourable one of the vertex. 

His mode of accomplishing cephalic version is thus described : — 

" Suppose the patient to have been placed upon her back, across the bed, and 
with her hips near its edge — the presentation to be the right shoulder, with the 
head in the left iliac fossa — the right hand to have been introduced into the 
vagina, and the arm, if prolapsed, having been placed, as near as may be, in its 
original position across the breast. We now apply our fingers upon the top of 
the shoulder, and our thumb in the opposite axilla, or on such part as will give 
us command of the chest and enable us to apply a degree of lateral force. Our 
left hand is applied to the abdomen of the patient, over the breech of the foetus. 
Lateral pressure is made upon the shoulders in such a way as to give to the body 
of the foetus a curvilinear movement. At the same time, the left hand, applied 
as above, makes pressure so as to dislodge the breech, as it were, and move it 
towards the centre of the uterine cavity. The body is thus made to assume its 
original bent position, the points of contact with the uterus are loosened, and 
perhaps diminished, and the force of adhesion is in a good degree overcome. 
Without any direct action upon the head it gradually approaches the superior 
strait, falls into the opening, and will, in all probability^ adjust itself as a favour- 
able vertex-presentation. If not, the head may be acted upon as in deviated 
positions of the vertex, or it maybe grasped, brought into the strait, and placed 
in correspondence with one of the oblique diameters. 

" It will be observed, that we do not act upon the shoulders by raising them. 
Perhaps a slight elevation would facilitate the movement already described — 



1855.] Wright, Difficult Labours and their Treatment. 



153 



or it miglit be better to depress them — and, again, by lateral pressure, without 
either elevation or depression, our object miglit be accomplished. FusJiing up 
the shoulders, therefore, does not constitute a prominent part of turning, if by 
pushing up is meant the mere raising of the shoulders above the brim of the 
pelvis. 

"As the body of the foetus makes its curved movement under the hand of the 
operator, it advances upward, as well as laterally, by a combined rather than a 
single action, which would give it only one direction. 

*' The back of the hand, with which we have been acting upon the shoulder, 
is toward the head of the foetus — consequently, its hold upon the head would 
be, apparently, slight — yet, after the shoulders have reached the iliac fossa, the 
vertex may fall upon the palm of the hand in occupying the strait, and its 
adjustment become easy. If, however, there should seem to be a necessity for 
grasping the occiput, there could be no reasonable objection to a speedy change 
of hands. 

" The entire process of cephalic version is to be adopted in the absence of 
uterine contraction ; or, rather, during the intervals of expulsive force. And, 
as it is now a vertex-presentation, we must be governed, as to the time and 
manner of delivery, by those general rules applicable to such cases.-'^ 

Dr. Wright informs us that in all his cases, excepting one which terminated 
as a face-presentation, the occiput assumed a position corresponding with the 
first or second of the vertex. In the exceptional case the occiput was before 
one of the sacro-iliac symphyses, and to this fact Dr. W. attributes the tendency 
of the occiput to slide above the brim of the pelvis, and the difficulty of keeping 
it in place. He thinks, however, that if there had been the usual degree of ute- 
rine contraction, the head would in all probability, have become fixed, and the 
presentation would have continued as one of the vertex, instead of changing for 
the face. 

In all the obstetrical works we have examined," remarks Dr. W., " in which 
cephalic version is recommended by internal manoeuvre, it is directed to raise 
the shoulder as the first necessary impression upon the foetus. Viewed anato- 
mically or mecha.nically, men have not been persuaded into the belief, that 
raising the shoulder can facilitate the permanent descent of the head into the 
superior strait. We maintain, what is apparent to the eye in viewing a proper 
engraving, and as can be demonstrated with the manikin, that the elevation of 
the shoulder at the brim of the pelvis, tends to increase the long diameter of 
the foetus, and the transverse diameter of the uterus, and without any favour- 
able adjustment of the head after pressure upon the shoulder has been with- 
drawn. 

" Suppose we follow out the directions given by some, and, after the elevation 
of the shoulder, attempt to force the body of the foetus in a lateral direction, will 
not the breech impinge against the walls of the uterus transversely ? To enable 
the head to engage in the superior strait, the body must be entirely moved 
from it, and this can only be done by raising the breech towards the fundus of 
the uterus. Raising the shoulder, therefore, is very naturally considered a 
means to prevent cephalic version. Hence we are not surprised that podalic 
version is almost universally adopted in the treatment of shoulder-presenta- 
tions,'^ 

If experience shall prove the views of Dr. Wright, as set forth in his essay, to 
be correct; if it shall be found that cephalic version, in the manner practised 
by him, can be as readily efi'ected as he contends, he has certainly made a most 
important contribution to the practice of obstetrics. 

Shoulder-presentations are, happily, of comparatively rare occurrence. Sel- 
dom, however, as they are met with, every obstetrician will, nevertheless, 
rejoice, shall it be found that the risk incurred by both mother and child in 
the usual mode of managing such cases, by turning so as to deliver by the feet, 
or by evisceration and extraction by the crotchet, can be obviated by so easy 
and simple a manoeuvre as cephalic version is described to be by Dr. Wright. 

D. F. C. 



154 



BihliograpMcal Notices. 



[July 



Art. XX. — Lectures in reply to tlie Croonian Lectures for 1854, of Charles 
West, of London, on the Pathological Importance of Ulceration of the Os Uteri. 
By Henry Miller, M. D., Professor of Obstetric Medicine In the University 
of Louisville, etc. etc. From the Western Journal of Medicine. 8vo. pp. 71. 
Louisville, Ky., 1855. 

In his review of Dr. West's lectures, Professor Miller appears to us to have 
overlooked the leading question discussed in them — the pathological import- 
ance of ulceration of the os uteri — and he has, consequently, brought a large 
amount of heavy artillery to bear upon a fortress which it does not appear that 
Dr. West had attempted to garrison or defend. 

Dr. Miller must be aware of the very high rank that has of late years been 
assigned, in female pathology, to simple ulceration of the neck and mouth of 
the uterus. There are, in fact, physicians who would seem to refer to it nearly 
every uneasy sensation, every indication of disturbed health met with in the 
female, from puberty to the close of life, and whose therapeutics, in the major 
portion of her ailments, is circumscribed almost exclusively to the local appli- 
cation of nitrate of silver and other caustics, for the purpose of healing the 
ulcers which, with them, have, in a great measure, been constituted fons et 
origo morhorum foemince. While we have another class of physicians who con- 
sider these ulcers of comparatively unfrequent occurrence, or, when present, 
of secondary importance to the more grave diseases of which they are the 
result. The inquiry, therefore, into what is the actual pathological importance 
of ulceration of the os uteri would appear to be a very natural and proper one. 
This inquiry has been undertaken by Dr. West, and the mode in which he has 
conducted it, and the conclusions at which he has arrived having been presented 
to the profession, are fair subjects for criticism. If his facts, his arguments, or 
his deductions are erroneous, the cause of truth and of humanity requires that 
this should be made known, and a currency given to the exposition of his error 
or errors co-extensive with that which has been given to the latter. It is import- 
ant, however, in testing the accuracy of the conclusions at which the inquirer has 
arrived, and the correctness of the process pursued by him in his investigation 
of the question at issue, that the real object and scope of his labours should be 
kept constantly in view, and all impeachment of improper motives and unfair- 
ness of conduct avoided. We are sorry to say that this course has not always 
been strictly observed by Professor Miller in his reply to the lectures of Dr. 
West. 

One would suppose, from the general tenor of the criticism before us, that 
the inquiry undertaken by the Croonian lecturer for 1854, was into the general 
pathology of the uterus, instead of being restricted to the pathological import- 
ance of ulceration of the os uteri. 

Professor Miller admits that the manner in which Dr. West has conducted 
the inquiry which constitutes the subject of his lectures "is courteous and dig- 
nified and yet he has not hesitated to accuse him of unfairness ; of resorting 
to dishonourable means to disparage, and, " to the extent of his abilities," 
render contemptible the doctrine and practice of those from whom he differs ; 
of the artifice of mutilating statements to suit his views; of the "vice of dis- 
simulation of " an apparent ingenuousness,'^ designed to entrap the unwary 
reader; of dealing, " throughout his lectures,'' in logical tricks, etc. etc. 

Noticing the different results arrived at by Drs. Lee and West, from their 
respective examinations of the bodies of females, with the view of determining 
the frequency of the occurrence of lesions of the os and cervix uteri, Professor 
Miller asks, " How are we to reconcile this discrepancy between Dr. Lee and 
Dr. West? How, but by supposing that each found what he sought, and what 
he judged would be most effective in arresting the progress of the speculum. 
Prejudice is proverbially blinding in its influence, and under its dominion Dr. 
Lee, and those who saw for him, may not have seen what was plainly before 
their eyes ; but it may likewise sharpen the sight, as in the case of Dr. West, 
and enable it to see what is hid from others." 



1855.] Kirkbride, Construction^ etc.^ of Hospitals for the Insane. 155 



"We regret to find such a charge made by a gentleman holding so high and 
responsible a position in our profession as Professor Miller, and one who, by his 
talents and industry, has won for himself so fair a reputation. Admit the posi- 
tion he has assumed as correct, and we at once destroy the value of statistics in 
the settlement of any disputed medical question. And we would suggest that, if 
there is any weight in the accusation brought against Drs. Lee and West as to 
the " einseitig und unrechtig" manner in which their observations have been 
made and reported, the same accusation may with equal force be brought 
against the authority of Professor Miller's statements in regard to the result of 
his own examinations of the os and cervix uteri, in females labouring under 
sexual complaints ; for we have no more evidence of prejudice on the part of 
either Dr. Lee or Dr. West, in regard to their views of uterine pathology, than 
we have of prejudice on his part in regard to his. 

Let us have some faith in medical testimony. Though we may be forced to 
point out, in the statistics furnished us in support of one or other side of a 
disputed question, their inconclusiveness, in consequence of their limited cha- 
racter; their deficiency in various important points; their irrelevance to the 
question at issue ; or their entire disagreement with others of a more extended, 
accurate, detailed, or relevant character, let us not doubt the honesty and good 
faith of those from whom they have emanated — especially when we know them 
to be distinguished and reputable members of the profession. 

We confess that we have failed to detect any evidence of a partisan character 
in the Croonian lectures of Dr. West; they certainly exhibit much less of a par- 
tisan spirit than the lectures in reply of Professor Miller. Dr. West's mode of 
conducting the investigation of the pathological importance of ulceration of the 
OS uteri may be shown to be erroneous, his reasoning defective, and all his 
conclusions false ; but, from neither the language nor general tone of his lec- 
tures, have we any ground for inferring that he undertook the inquiry they are 
intended to elucidate with any bias for or against the views at which he has 
arrived, or for any other object than to arrive at truth. 

It is not our intention to take any part in the controversy which has given 
rise to the lectures of Drs. West and Miller. We have made, it is true, quite 
a number of examinations, with the speculum, of the os and cervix uteri in 
females labouring under sexual diseases, and in others in whom we were led 
to suspect some affection of the lower portion of the womb ; and in these exami- 
nations we have often detected unquestionable inflammation and ulceration, or 
hypertrophy of its neck and mouth ; nevertheless, judging from our own exami- 
nations, and those at which we have assisted in patients under the care of other 
physicians, we have arrived at the conclusion that the frequency of inflamma- 
tion and ulceration of these parts has been greatly exaggerated. Mere epi- 
thelial abrasions have unquestionably been taken for ulcerations, and a 
relaxed and engorged condition of the cervix for a state of chronic inflamma- 
tion and enlargement — of the non-dependence of these abrasions and engorge- 
ments upon inflammation, we feel fully satisfied. Although of themselves of 
secondary importance, yet we cannot but view the condition of the cervix 
uteri under which these most commonly occur, as one demanding the closest 
attention on the part of the practitioner. We are far, however, from consider- 
ing it to be one in which the application of the nitrate of silver, or any other 
caustic, will be found generally beneficial or curative. D. F. C. 



Art. XXI. — On the Construction, Organization, and General Arrangements of 
Hospitals for the Insane. By Thomas S. Kirkbride, M. D., Physician to the 
Pennsylvania Hospital for the Insane. Philadelphia, Lindsay & Blakiston, 
1854. 8vo., pp. 80. 

No other class of men in our country, not even professional architects, have 
so generally made the structure of buildings for the accommodation and treat- 



156 



BihUograpTiical Notices. 



[July 



ment of the insane a subject of study, as the superintendents of the several 
hospitals of that description ; and, of these, no one has investigated it with 
more assiduity, or more thoroughly, than Dr. Kirkbride. A " residence of 
sixteen years among the insane, in three different institutions, the last thirteen 
of the time being in immediate superintendence of that with which he is con- 
nected, and the care of more than 2,700 patients under very varied circum- 
stances, joined to a familiarity with the defects as well as the advantages of a 
majority of the American Hospitals," have given him opportunities enjoyed by 
but few to make himself familiar with all the necessities, both material and 
moral, to the proper treatment of the subjects of mental alienation. He has 
not neglected those opportunities, and the results of his researches, observa- 
tions, and reflections are now before us, in what we venture to pronounce the 
best and most nearly perfect work of the kind which has ever been produced. 

The subject is treated as if this proposition had been laid before the author 
for demonstration : Given ; two hundred and fifty unhoused insane persons, one- 
Tialf of each sex, and all of such classes and conditions as are admitted into our 
State hospitals ; that is, part pay patients and part paupers, part curable and 
part incurahle, and ijicluding among them, all forms and degrees of the disease ; 
that combination of the means and facilities for their treatment required which 
shall he most ejfective towards the attainment of the ends, primarily and para- 
mountly, of restoration to health of the curable, and the greatest comfort, and 
bodily and mental improvement of the incurable ; and secondarily, and so far 
subordinately as not to infringe upon the former, the best economy of pecuniary 
expenditure. 

He has answered it by giving a plan of a building, with illustrations of the 
architecture, both external and internal ; remarks upon the site, the amount of 
land, supply of water, drainage and inclosures ; descriptions of the general 
arrangements of the buildings, the cellar, materials of the walls, plastering, 
roof, floors, doors, locks, stairs, windows, bath-rooms, water-closets, sinks, 
dust-flues, dumb-waiters, speaking-tubes, baking, washing, drying, and ironing 
arrangements, and many other things which need not here be mentioned in 
detail. 

No subject of importance in the construction of the buildings is left unno- 
ticed in the first part of the essay. The second part is devoted to " Organiza- 
tion and General Arrangements." Here is an exposition of the duties of the 
Trustees, the Treasurer, the Physician and Assistant Physicians, the Steward, 
Matron, Chaplain, and Consulting Physicians, as well as of all the subordinate 
employees properly appertaining to the establishment. Among the other sub- 
jects discussed are the following, viz. residence of the physician ; hospital 
furniture ; classification of patients ; should curables and incurables be sepa- 
rated ? separation of the sexes ; restraint and seclusion; labour, out-door exer- 
cise, and amusements ; means of extinguishing fire; supervision of hospitals 
for the insane ; provision for insane criminals ; visitors : admission of patients; 
importance of a correct nomenclature. 

An appendix contains the " Propositions relative to the Construction and 
Organization of Hospitals for the Insane," which have been adopted and issued 
by " The Association of Medical Superintendents of American Institutions for 
the Insane." 

From what has been said, it may readily and correctly be inferred that, for 
all who are in any way connected with institutions contemplated in it, this 
book is full of interesting matter, and that to all who are about to be engaged 
in the construction of a hospital for the insane, it will be indispensable. 

Nor is its scope thus limited. The trustees, managers, architects, and offi- 
cers of general hospitals, prisons, institutions for the blind, for deaf-mutes, or 
for orphans — in short, of any large public establishment intended for the 
accommodation of numerous inmates, may find much in it which will not only 
interest, but instruct. 

The very nature of the essay precludes the possibility of utility from the 
garbled extracts which might be embodied in so brief a notice as that to which 
we are limited. An elaborate review alone could do it justice. We commend 
the work itself to all who might be interested in such a review. P. E. 



1855,] Tuke, CJianges in Management of Insane. 



157 



Art. XXII. — 1. The Progressive Changes which have taken place, since the time of 
Pinel, in the Moral Management of the Insane ; and the various Contrivances 
which have been adopted instead of Mechanical Restraint. By Daniel H. Tuke, 
M. D., Assistant Medical Officer of the York lletreat, &c., &c. London ; 
John Churchill, 1854. 

2. The Asylums of Holland ; their Past and Present Condition. By Daniel H. 
Tuke, M.D. From the PsychologicalJournal, July 1, 1854. 

In our notice of the report of the Trustees of the Massachusetts State Luna- 
tic Hospital, in the issue for April, 1855, of this Journal, it was asserted that 
" no man named Tuke was ever Superintendent" of the York lletreat, and that 

we never heard, in England, of any Doctor Tuke.'^ The sheets of the Jour- 
nal were hardly dry, when we received, from their author, the book and the 
pamphlet, the titles of which are hereto superposed. There is, therefore, a 
Doctor Tuke in England, and he is connected with the York Retreat.' These 
facts, however, do not militate against the truth of the assertions above quoted. 
Doctor Tuke is the great-grandson of him whom the Trustees aforesaid "dubbed 
a doctor and when, for several days, we sojourned in the hospitable house of 
his father, and took notes of our visit to the Retreat, sitting in the invalid chair 
made for, and, for many years, occupied by the " father of English grammar," 
Lindley Murray, he was a lad whose greatest cares and griefs were undoubtedly 
in his satchel, and whose thoughts were less upon a prospective profession than 
upon the trundling of a hoop, or playing hide-and-seek among the ivy, the 
laurels, and the other shrubbery of his father's garden. 

The " Society for Improving the Condition of the Insane," which was insti- 
tuted in 1842, by the late Earl of Shaftesbury, annually offers premiums for 
essays upon subjects relative to mental diseases. The essay by Dr. Tuke ob- 
tained the prize in 1854, and was published by the Society. It is a concise but 
very comprehensive narrative, with succinct descriptions of the means of me- 
chanical restraint which have been employed, and the " contrivances" which 
have been substituted for such restraints. For all who are interested in the 
insane, it is fraught with interest; and in no other place can so complete a com- 
pend of the history of the reformation of asylums be found. 

The first chapter is devoted to an exposition of the moral treatment of the 
insane, at the time of Pinel, and of the labours of that reformer ; the second, 
to a history of the reformatory progress in France, during the first half century 
after its commencement. 

Chapter third contains a brief account of the gleanings of the author in a 
tour of observation among the hospitals for the insane upon the Continent, in 
1853. Among the prominent men in this department of the medical profession, 
Professor Schroeder Van der Kolk and Dr. Raemer, in Holland ; Professor 
Ideler, and Drs. Jacobi, Damerow, Martini, and Leubruscher, in Prussia ^ Drs. 
Riedel and Kcestle, in Austria ; Zeller in Wurtemberg ; Roller in Baden Klotz 
in Saxony ; and Falret and Voisin, in Paris. Not one approves of the system 
of non-restraint by mechanical apparatus, in the treatment of the insane. 
*' But," says the author, *' on hearing them expre&s their opinion on this sub- 
ject, I at once inquired into the means employed to restrain their violent patients, 
and usually found, with real disappointment, that they had by no means sys- 
tematically introduced those various appliances without which the experiment 
cannot fairly be tried." 

The subjoined remarks were elicited by a visit to the excellent asylums at 
Vienna and Prague. 

" Prejudiced, as an Englishman is, against the political system of Austria, 
he naturally expects to find her institutions in a bad condition. At least, this 
was my case ; but I am glad to say that, in regard to lunatic asylums, I was 

' Dr. Harrington Tuke has charge of the Manor House, an Asylum at Chiswick, 
near London. 

No. LIX.— July 1855. 11 



15S 



BihUograpTiical Notices. 



[July 



agreeably disappointed. There are bad asylums in Austria, it is true ; so there 
are in England ; but those recently built are worthy of all praise, not only in 
their construction and external appearance, but in their management, the con- 
dition of the patients, and the high character of their medical o£5cers/^ 

Our author was " struck with the superiority of continental asylums over 
our own (the English) in one particular—the greater proportion of medical 
officers to the patients/^ As proof of this, he cites the fact that at Illenan, in 
Baden, an institution with 450 patients, there are five resident physicians. We 
were forcibly impressed with the same superiority over the American hos- 
pitals for the insane, and may add to the example alleged by Dr. Tuke, those 
of Siegberg, Sonnenstein, and Leubus, at each of which there are three phy- 
sicians to superintend the management of from 150 to 225 patients. At Hall, 
in Tyrolese Austria, there are also three, and the number of patients rarely 
exceeds 110. In short, so far as our observation has extended, none of the con- 
tinental institutions having one hundred patients, are supplied with less than 
two, sometimes three, medical officers. 

The "successive changes in the moral treatment of the insane in England," 
from 1792 to 1814, form the subjects of the fourth chapter of the essay. Opin- 
ions have differed in regard to the question of merit, as pioneer in the reformed 
method of treating the insane, between Pinel and the founders of the Retreat. 
Dr. Tuke, with a justifiable delicacy, does not directly allude to this subject, 
but, quoting from Dr. Thurnam in one place, and condensing from the British 
and Foreign Medical Revievj, in another, he makes it appear that " it was in the 
spring of 1792 that the establishment of the Retreat was proposed by the late 
William Tuke,"^ and that, " towards the end of 1792, Pinel, after having many 
times urged the Government to allow him to unchain the maniacs of the Bicetre, 
but in vain, went himself to the authorities, and with much earnestness and 
warmth, advocated the removal of this monstrous abuse." With Thurnam, he 
appears to think that neither of those men was aware of the action of the other, 
and that the approximative simultaneity of their enterprises was but " a singu- 
lar and interesting coincidence." But, as proof of the disinterestedness and 
universality of his philanthropy, he closes this chapter of strange expositions 
and interesting undertakings, as follows 

"All honour to the men, whether in our country or in France, whose warm 
hearts and enlightened judgments perceived the inhumanity of the system they 
found, and, relying on the justice of their cause, broke in pieces the iron mana- 
cles which confounded the lunatic with the felon, and swept away that mass of 
inhuman treatment which reduced him to a level with the brute. ^Egregia sane 
laus ! Froeclarum enim humanitas atque disciplina de harharie reportavit vie- 
toriamJ " 

Chapter fifth continues the history from 1814 to 1839. In the course of this 
period (in 1823), Sir Alexander Morison commenced his lectures on mental dis- 
eases, fifteen new asylums were opened, and, near its close, in 1838, it was pro- 
mulgated as a principle, by Mr. Hill, of the Lincoln Asylum, that "in a properly 
constructed building, with a sufficient number of suitable attendants, restraint 
is never necessary, 7iever justifiable, and always injurious, in all cases of lunacy 
whatever '^'^ 

One of those strange realities of the present day, which to the physician, the 
philosopher, or any man of the times of the American revolution, would have 
appeared but as the dreams of an enthusiast or the chimeras of a mental alien, 
is exhibited in the history of the Lincoln Asylum, in its progressive melioration 
of the condition of its patients. 

In 1829, it was ordered by the Board of Managers: " 1. That the heaviest 
pair of iron hobbles (weight 3 lbs. 8 oz.) and the heaviest pair of handcuffs 
(weight 1 lb. 5 oz.) be destroyed ; 2. That, of the eleven strait waistcoats now 
belonging to the house, the worst five be destroyed." 

» Born 1732, died 1832. This grandson, Samuel Tuke, also one of the managers 
of the Retreat, and father of Dr. Tuke, wrote, in 1813, the "Description of that In- 
stitution," which attracted so much attention in all countries where an interest in tiie 
welfare of the insane had been developed. 

2 Hill on Lunatic Asylums, 1838. 



1855.] Tuke, Changes in Management of Insane. 159 



In 1830, of the 92 patients, 54 were placed under restraint an aggregate of 
2,364 times, and so kept during an aggregate of 27,113 hours. 

In 1833, patients 87, restrained 44, times 1,109, total of hours 12,003. 
" 1836, " 115, 12, " 39, 324. 

From March, 1837, all mechanical restraints were discontinued. 

The credit of commencing and prosecuting this reform, to 1835, is due to Dr. 
Charlesworth; the completion of it, to Dr. Hill. 

The sixth chapter is a continuation of the history to the year 1854. Dr. 
ConoUy became connected with the Hanwell Asylum, then containing 800 
patients, in 1839, and in the course of that year removed the coercion {douce- 
merit "tranquillizing") chairs, "about forty in number," from the wards, and 
abolished the use of strait waistcoats, hand-straps, leg-locks, and all contriv- 
ances confining the trunk, limbs, or any of the muscles. Since that time, 
the non-restraint system has been adopted at several institutions ; but, as late 
as 1844, there were others in which the condition of the patients was as cen- 
surable as that of those in the Bicetre anteriorly to the labours of Pinel. 

Chapter eight includes an enumeration and description of the " contrivances 
adopted in the place of mechanical restraint." 

" We do not hesitate to assert," says the author, " that, under a defective 
moral system of government, an inefiicient superintendent, and attendants not 
of the highest moral stamp, any asylum discarding mechanical restraint will 
not only not have gained any real advantage, but will probably have exposed 
the patients to another, and it is possible to a worse form of coercion. * ^ 
Hence, then, of primary importance in the consideration of the substitutes for 
restraint, is the moral character of the government of the asylum — using the 
term in its largest sense. With it, the non-restraint system is practicable and 
beneficial ; without it, however high-sounding and grateful to the public ear, 
the system carries with it a very questionable advantage." 

In place of a more detailed notice of the substitutes, we give the resume of 
the author, afc the close of the chapter and of the book. 

" It must be confessed that when we have obtained all that is to be desired 
in the superintendence, attendance, and the construction of the building, the 
particular contrivances are few, simple, and readily applied. They may be 
thus summed up : The seclusion-room, including the padded room ; a strong 
dress, as of ticking, secured by locks ; the manual strength of attendants, in 
rare cases ; cases for blankets, &c. (to prevent them from being torn) ; and, 
lastly, cold affusions, topical depletion, and medicines of a depressing charac- 
ter." 

Two other extracts from this chapter will be read with interest. 

" It is a curious and interesting fact that suicides occur less frequently with- 
out restraint than with it." 

" We have again and again witnessed the effect of removing a violent patient 
to a padded room, and have watched, through the inspection-plate, the expres- 
sion of the patient, and his actions when left to himself, and, as he conceived, 
unwatched ; and we can truly say that, in many instances, the patient who a 
minute before was in the most frantic condition — kicking, striking, and swear- 
ing — was instantly subdued ; and in the great majority of cases the same event 
happened after no very long interval. The entire silence of the room, the ab- 
sence of excitement, the impossibility of hurting anything or anybody, appear 
to convince the patient of the utter uselessness of yielding to his impulses." 

The present position of the subject of non-restraint, in England, is thus stated, 
near the conclusion of the seventh chapter : — 

" The abolition of restraint in all cases whatever must still be regarded as 
- an open question, although the current of popular and of medical opinion is 
strong in its favour ; but at whatever conclusion the friends of the insane arrive, 
we are sure that all will agree with the author of the ' Description of the Re- 
treat,^ when he says : ' With regard to the necessity of coercion, I have no hesi- 
tation in saying that it will diminish or increase, as the moral treatment of the 
patient is more or less judicious.' ^' 

" Our own opinion of the question is so precisely expressed in the following 



160 



Bibliographical Notices. 



[July 



remarks, taken from the third report of the "Wilts Asylum, that we shall con- 
clude the subject by introducing them here : ' The writer is not of opinion that 
in no possible case is it justifiable or proper to have recourse to personal re- 
straint, but he entertains a very strong conviction that the officers and attend- 
ants in an asylum should be trained to its habitual disuse ; and that it should 
on no account be resorted to by the medical officer in charge, except upon very 
grave deliberation, and after the failure of all other methods/ " 

In a hrocTiure of between twenty and thirty pages, Dr. Tuke has produced 
the most full and detailed description of the asylums of Holland that we have 
seen, together with their statistics, and a history of the reformation of those 
institutions. 

"The condition of the insane in Holland," says he, "half a century ago, 
was no less deplorable than in other countries." The first evidence of a move- 
ment towards improvement was in February, 1813, when an " Act of King 
William I. facilitated the admission of recent cases of insanity into the asy- 
lums, previously the receptacles for chronic cases only," In 1816 a census of 
the insane was taken, but led to no measures of melioration. In 1825, another 
census showed that there were 868 men, 960 women, a total of 1,828 insane, in 
a population of 2,253,794, equal to 1 in 1,232. "Of these 1,828, 702 were con- 
fined in 47 distinct places — prisons, workhouses, poorhouses, hospitals, &c. ; 
only 23 of these abodes being houses specially for the insane, and not one really 
and truly adapted to their treatment." War with Belgium prevented progress 
in this sphere, by government, from 1830 to 1833, but " the Directors of the 
Utrecht Asylum commenced the work of reformation in that establishment, and 
this attempt may be considered as the point de depart from which all subsequent 
improvements in the Dutch asylums proceeded. * * * * Professor Van 
der Kolk, the physician to the Asylum, pioneered the way in this noble cause, 
* * * * -x- jje must be regarded as the Pinel of Holland." 

In 1838, a third census gave 931 men, 996 women, a total of 1,925 insane, in 
a population of 2,583,271 — equal to 1 in 1,336. In May, 1841, "an act was 
passed for the purposes of reforming the abuses of asylums, which has been of 
so much use in achieving its object — that, in ten years all unfit houses of this 
description have been abolished. Two Commissioners in Lunacy, one of them 
Prof. Yan der Kolk, were also appointed with "full power to inspect all asy- 
lums, and report on their condition to the Minister of Home Affairs." Of 32 
asylums, or "houses," visited by them in 1842, only three — Utrecht, Zutphen, 
and Deventer — were approved. Government immediately ordered a large part 
of the others to be closed, "while the rest were left to the more gradual influ- 
ence of the reformatory act" already mentioned. In December, 1850, "only 
six houses for the confinement of chronic cases remained" — number of all their 
patients, 51. These also will soon be closed. 

"In 1850, the population of Holland was 3,056,591 ; number of asylums, 11 ; 
patients, 1,263 ; insane 7ioi in asylums, 1,793, estimating the whole number 
upon the basis of 1 to each 1,000 inhabitants. Professor Yan der Kolk thinks 
this estimate too low, and that 1 to 800 would be more nearly accurate. Asy- 
lums with a resident physician, three — Deventer, Zutphen, and Meerenberg;* 
provincial asylums, one — Meerenberg. Private asylums are not now (1853) 
allowed in Holland." 

Dr. Tuke visited all the principal Dutch asylums at Meerenberg (near Haar- 
lem), of which he gives an elaborate and interesting description ; there were 
21 males and 25 female epileptics. " Yery minute observations are made of the 
circumstances attending their fits — the temperature, the state of the barometer, 
the hour of the day, the night, &c. Dr. Everts finds that the fits of the women 
are more frequent between 9 P. M. and 9 A. M., than at other times, and 
most frequent at midnight. On the contrary, with the men, the attacks were 
of more frequent occurrence in the day." 

1 Since 1850, Resident Medical Superintendents have been appointed to the asy- 
lums at Utrecht and Dortrecht ; and friesland has opened a provincial asylum at 
Francher. 



1855.] 



Brown-Sequard, Spinal Cord, etc. 



161 



" As regards medical treatment, I may just state that general bleeding is very 
rarely employed ; when it is, the cases are usually apoplectic, and not maniacal. 
Topical depletion by leeches and cupping is much more frequently resorted 
to, Dr. Everts stating that the latter would be employed at least once daily. 
(Xumber of patients, at the time of Dr. T/s visit, 391.) Tunod's ventouse 
monstre is also considered of great service in deriving the blood from the spinal 
cord and cerebrum, and in restoring the catamenia, in hysterical mania. Eme- 
tics are occasionally found of use." 

In 1851, the average resident number of patients was 297 ; average attending 
worship, 114 ; engaged in icorJc, 190 ; under restraint, 7. 

Men. Women. Total. 

The number of epileptics was 25 18 43 

Number of fits by day (9 A. M. to 9 P. M.) 1,600 2,415 4,015 
night(9 P.M. to 9 A. M.) 1,372 3,435 4,807 

At the Asylum of Utrecht, " during the first thirty years of the century, the 
mortality, calculated on the admissions, was 35 per cent. : during the last five 
years, only 17 per cent.-" 

"Dr. Ramaer (of the Asylum at Zutphen) constantly finds a much larger 
proportion of noisy patients among the women than the men ; at present there 
are nearly twice as many of the former more or less excited. On mentioning 

this to , as a reproach on the gentler sex, she argued that it was 

natural to suppose women would be more noisy than men, when insane, because 
they are so much less so when they are sane!" 

We extract the aggregate statistics of the Dutch asylums for the seven years 
next preceding December 31, 1850 : — 

Men. Women. Total. 

Patients in the asylums January 1, 1844 . 424 413 837 

Of these, there were cured in the seven years . 56 44 100 

Died . . ^ 159 165 324 

Number admitted in course of the same years . 1,590 1,497 3,087 

Of these, there were cured .... 477 523 1,000 

Died _ 474 327 801 

Remaining, of both the above classes, Dec. 31, 

1850 619 657 1,276 

Average number resident during seven years . 608 502 1,110 

Mean annual mortality, per cent., resident . 15.1 13.9 14.5 

In a review of the asylums generally. Dr. T. remarks that it is " evident that 
they are not yet perfect. A great work of reform, however, has been com- 
menced; and, considering the period of time which has elapsed, I think that 
the progress made in the amelioration of the condition of the insane is highly 
satisfactory. One noble institution (Meerenberg) has been reared, of which any 
country might justly be proud; an institution which, itself the indication and 
result of the reform in Holland, will in its turn act as the nucleus of an extended 
improvement in the management of Dutch asylums.'^ P. E. 



Art. XXIII. — Experimental and Clinical Eesearclies on the Physiology and 
Pathology of the Spinal Cord, and some other parts of the yervoits Centres. 
By E. Browx-Sequard, M. D., of Paris, Professor of the Institutes of Medi- 
cine and of Medical Jurisprudence in the Medical College of Virginia, etc. 
8vo. pp. 66. Richmond, 1855, 

This, like all of Dr. Sequard's former contributions to physiology, will be 
found deeply interesting to the pathologist. In his investigation of an im- 
portant class of diseases dependent upon lesions of diflFerent portions of the 
nervous centres, the present researches will afford him material aid. The ob- 
ject for which they were undertaken is to determine the place of decussation 
of the sensitive and voluntary motor nerve-fibres in the cerebro-spinal axis. 



162 



BihliograpMcal Notices. 



[July 



This question Dr. Sequard has attempted to solve by a series of vivisections, 
the correctness of the results derived from these being tested by numerous 
clinical observations, in which the disturbance of motion or of sensibility dur- 
ing life was carefully compared with the lesions of the nervous centres dis- 
covered after death. 

The generally received explanation of the fact that an alteration of the brain 
on one side produces a loss or diminution of sensibility and of voluntary move- 
ments on the opposite side of the body, is that the sensitive and motor nerve- 
fibres proceed to the encephalon along the spinal cord without decussating, but 
that, when they have arrived at the medulla oblongata, they begin to decus- 
sate, and continue to do so along the middle line of what is now termed the 
Isthmus of the Encephalon (medulla oblongata, pons Varolii, crura cerebri, cor- 
pora quadrigemina, etc.). 

This explanation Dr. S. has endeavoured to show to be entirely erroneous, 
and to prove that the sensitive nerve-fibres decussate almost exclusively in the 
spinal cord, while the voluntarj motor nerve-fibres decussate mostly in the 
inferior portion of the m^edulla oblongata. 

The facts developed by the vivisections performed by Dr. S., in proof of a 
crossing of action for sensibility in the spinal cord, are as follows : — 

" 1st. If a lateral half of the spinal cord is divided transversely at the level 
of the tenth costal vertebra, on a mammal, it is found that sensibility is much 
diminished, and, in some cases, entirely abolished in the posterior limb oppo- 
site to the side of the section. On the contrary, the sensibility, far from being 
lost, appears to be much increased in the posterior limb of the side where the 
section has been made. 

"2d. If, instead of one transverse half section of the cord, two, three, or 
more are made on the same side, the same efi'ects are observed. 

" 3d. If, instead of mere sections, a removal of a lateral half of the spinal 
marrow is effected, the same results are still observed. 

" 4th. If the lateral section is not complete, and if the part left undivided is 
in the neighbourhood of the centre of the cord, it is found that sensibility 
appears to be increased in the posterior limb of the same side, and that in the 
other posterior limb there is only a slight diminution of sensibility. If the 
part left undivided is considerable, sensibility does not appear to be diminished 
in this last limb, and sometimes it seems rather increased. 

" 5th. If, in performing the section of a lateral half of the spinal cord, the 
instrument goes a little too far, and divides also a small portion of the other 
half in the central part, then the posterior limb on the side of the complete 
section is less sensitive than in the normal state, and the posterior limb of the 
opposite side loses completely its sensibility. 

"6th. If the section of a lateral half of the spinal cord is made at the level of 
the second or third cervical vertebra, it is found that sensibility becomes very 
quickly much greater in the parts of the body on the side of the section, and 
that, on the contrary, the parts on the other side become evidently less sensitive. 

" 7th. If, after a section of a lateral half of the spinal cord at the level of the 
eleventh costal vertebra, we perform the section of the other lateral half at the 
level of the sixth costal vertebra, so that the two lateral halves of the cord 
are cut transversely, we find that sensibility is entirely lost, or very nearly so, 
in the two posterior limbs. Sometimes a very slight degree of sensibility re- 
mains, more particularly in the posterior limb on the side where the spinal 
cord has been divided at the level of the sixth costal vertebra. 

"8th. If two sections of lateral halves are made as in the preceding experiment, 
but at a greater distance from each other ; for instance, one on the right side, 
at the level of the eleventh costal vertebra, and the other on the left side, in 
the cervical region, nearly the same results are obtained as regards the poste- 
rior limbs, but the sensibility is increased in the right anterior limb, and it 
remains, though much diminished, in the left anterior limb. 

" 9th. If, after having divided transversely a lateral half of the spinal cord 
in the neck, at the level of the roots of the second pair of nerves, we lay bare 
the very sensitive nerves going to the ear, in dogs or rabbits, we find that their 
sensibility, on the side of the section of the cord, appears increased, and that. 



1855.] 



Brown-Sequard; Spinal Cord, etc. 



163 



on the contrary, on the other side, they appear either destitute of sensibility 
or very slightly sensitive. 

" iOth. Sections of a lateral half of the medulla oblongata give, as regards 
sensibility, the same results as sections of a lateral half of the spinal cord. 

" 11th. If a longitudinal section be made on the part of the spinal cord giv- 
ing nerves to the posterior extrepaities, so as to divide that part into two lateral 
halves, then it is found that sensibility is completely lost in the two posterior 
limbs, although voluntary movements take place in them. 

" 12th. If a similar separation of the two lateral halves of the spinal cord be 
made on the whole part supplying nerves to the anterior limbs, then we find 
sensibility is lost in both these limbs, and that it is only slightly diminished ia 
the posterior limbs. 

" 13th. If the same operation be made as in the preceding experiment, and 
if afterwards a transverse division be made on one of the lateral halves of the 
cord, in the part where the longitudinal section has been performed, then we 
find that the posterior limb on the side of the transverse section remains sensi- 
tive, while the opposite posterior limb loses its sensibility.'' 

In confirmation of the general conclusion drawn from the foregoing experi- 
ments, that very nearly all the sensitive nerve-fibres coming from the trunk 
and limbs cross each other in the spinal cord, and that, in consequence, the 
transmission of the sensitive impressions made upon one side of the body takes 
place almost entirely along the opposite side of the spinal cord. Dr. S. adduces 
a series of pathological facts, in which it is shov,-^n that an alteration of one 
side of the spinal cord is attended by a loss of or deficient sensibility on the 
opposite side of the body. The first portion of the series comprises cases of 
partial alterations of a lateral half of the cord, more or less conclusively prov- 
ing the decussation of sensitive nerve-fibres in that organ. The second portion 
of the series embraces cases of alteration of one side of the medulla oblongata 
or of the pons Varolii, which appear to Dr. S. to prove positively the decussa- 
tion in question. 

The next series of vivisections were undertaken to test the influence of a 
section of a lateral half of the spinal cord, and of the medulla oblongata, upon 
&oluntarj movements. From these experiments, and a num.ber of pathological 
facts adduced by Dr. S., he is led to admit one of the four following opinions^ 
each of which, he remarks, appears to be supported by some facts : — 

" 1st. The decussation of all the voluntary motor nerve-fibres takes place in 
the medulla oblongata, where the fibres of the lateral columns cross each other 
to form the anterior pyramids. 

" 2d. The decussation of the voluntary motor-fibres takes place partly in the 
medulla oblongata, but for a greater part in the pons Varolii, and in front of it. 

3d. The decussation of the voluntary motor-fibres takes place in the me- 
dulla oblongata and in the spinal cord. 

"4th. The decussation of the voluntary motor-fibres takes place together in 
the spinal cord, the medulla oblongata, the pons Varolii, and the parts in front 

of it:' 

The first of these opinions appears to Dr. S. to be somewhat too exclusive ; 
it is possible, he admits, that some few fibres go up to the pons Varolii, or stili 
higher, to make their decussation, but still there are strong reasons which pre- 
vent his admitting that such is positively so. It may be, also, that some fibres 
decussate in the spinal cord itself, although from pathological cases ybserved 
in man this would appear not to be the case. Dr. S. believes that if the ci'oss- 
ing of the pyramids do not contain all the voluntary motor nerve-fibres of the 
trunk and limbs, the number of these fibres which do not decussate there is 
but small. 

The general conclusions, therefore, of Dr. Sequard, from the experiments and 
observations referred to in the publication before us, are as follows : — 

" Ist. The sensitive nerve-fibres of the trunk and limbs appear to make the 
greatest part of their decussation, if not the whole of it, in the spinal cord, and 
aaot in the isthmus of the encephalon, as was generally admitted. 

*' 2d. The voluntary motor nerve-fibres of the trunk and limbs appear to make 
their whole decussation, or, at least, the greatest part of it, in the inferior por- 



16^ 



Bibliograpliical Notices. 



[July 



tion of the medulla oblongata, and not in the other parts of the isthmus of the 
encephalon, as was before admitted. 

"3d. According to the seat of an alteration in the cerebro-spinal axis, pro- 
ducing a paralysis, there are three different kinds of paralytic effects, which 
may exist. 

" a. The alteration being in any part of the encephalon, except the inferior 
portion of the medulla oblongata, the paralysis of voluntary movement and of 
sensibility exists in the side of the bod}^ opposite to the side of the disease. 

" h. The alteration occupying an entire lateral half of the inferior portion of 
the medulla oblongata, at the level of the decussation of the pyramids, the 
paralysis of voluntary movement exists on both sides of the body, but is incom- 
plete, and the paralysis of sensibility exists only on one side, and that opposite 
to the side of the disease. 

"c. The alteration occupying the entire thickness of a portion of a lateral 
half of the spinal cord, the parts of the body situated behind it, on the same 
side, are paralyzed in their voluntary movements, and the corresponding parts 
on the other side are paralyzed in their sensibility.'^ 

According to the investigations of Dr. S., three different forms of paralysis 
may be produced by an alteration of a lateral half of the cord, and all charac- 
terized by the existence of paralysis of movement on one side of the body, and 
a more or less extended paralysis of sensibility on both sides of the body. 

" 1. If an alteration, able to produce paralysis, exists in the whole thickness 
of a lateral half of the cord, in the entire extent of the part from which come 
all the nerves going to one of the upper limbs, there will be paralysis both of 
movement and of sensibility in that limb, and paralysis of movement in the 
trunk and the inferior limb, in the same side of the body, and besides, paraly- 
sis of sensibility in the opposite side of the bod}^ — limbs and trunk. 

" 2. If an alteration, able to produce paralysis, exists in the whole thickness 
and length of the part of a lateral half of the cord, which gives all the nerves 
going to one of the inferior limbs, there will be paralysis both of movement 
and of sensibility in that limb, and only paralysis of sensibility in the opposite 
limb. 

"3. If an alteration, able to produce paralysis, exists in the whole thickness 
and in the whole length of a lateral half of the cord, the symptoms will be a 
paralysis of movement in the side of the body corresponding to the side altered 
in the cord, and a paralysis of sensibility in the two sides of the body — neck, 
trunk, and the four limbs. 

"As the sensitive nerve-fibres, coming from one side of the body, have to 
pass through the corresponding side of the spinal cord to go to the opposite side 
of this organ, it is easy to understand that an alteration occupying the entire 
thickness of the cord is able to produce a paralj^sis of sensibility, together with 
a paralysis of movement, in the same side of the body. But it must be remem- 
bered that if, in such cases, the paralysis of movement exists in all parts of the 
body receiving their nerves from the altered part of the cord, and also from all 
the healthy parts below it— if there are any — the paralysis of sensibility, in the 
same side, remains limited, almost entirely, to the parts which receive their 
nerves from the altered portion of the spinal cord.'' 

Dr. S. presents a list of certain pathological and other facts which appear to 
be opposed to the deductions he has drawn from the facts and reasonings he 
has presented. These are arranged under the following heads : 1st. Alleged 
voluntary movement and apparent existence of sensibility in children who are 
to all appearance deprived of the cerebro-spinal axis. 2d. Alleged voluntary 
movements and apparent existence of sensibility in parts of the body considered 
as deprived of their natural connection with the encephalon. 3d. Alleged 
persistence of sensibility and voluntary movements in men and animals de- 
prived of all parts of the encephalon, except the medulla oblongata and pons 
varolii. 4th. Cases proving that considerable alterations of the pons varolii 
and medulla oblongata may exist without producing paralysis either of sensi- 
bility or of voluntary movements. 5th. Cases in which an alteration in the 
two sides of the pons varolii appeared to have produced a paralysis only in one 
side of the body. 6th. Cases in which an alteration existing in one side of the 



1855.] 



Grier, Yellow Fever. 



165 



pons varolii, or in the neighbouring parts, appears to have produced paralysis 
in both sides of the body. 7th. Cases in v^hich an alteration in one side of the 
pons varolii, or of the neighbouring parts, has produced paralysis in the same 
side of the body. 8th. Cases and experiments vv^hich appear to prove that 
there are, in various parts of the encephalon and in the spinal cord, motor 
nerve-fibres vrhich are not voluntary motor. 9th. Anatomico-pathological dis- 
sections — as those of Dr. L. Tiirck, of Vienna — which appear to prove that there 
are nerve-fibres coming from the spinal cord which decussate in parts above the 
medulla oblongata. 

After a careful examination of these several class of facts, Dr. S. presents 
the following as his conclusions in regard to them : — 

" 1st. That reflex movements alone, and not sensations and volitions, exist 
in monsters deprived of a great part of their cerebro-spinal axis. 

"2d. That, when the spinal cord, the medulla oblongata, or the pons varolii 
are altered, even considerably, sensibility and volition may continue to exist, 
because there are still communications by nerve-fibres through the altered 
parts, between the nerves of the trunk and limbs and the parts of the encepha- 
lon, in front of the pons. 

"3d. That, if the reasons given by many physiologists to prove that the pons 
Varolii is the seat of the centre for volition, and for perception of sensitive im- 
pressions, were true, we should have to admit that the medulla oblongata is 
the centre — or, at least, a part of the centre — for these faculties, because the 
same reasons appear to prove so for this organ as for the pons. 

" 4th. That very likely these faculties have not their centre, at least their 
principal centre, in the pons Varolii, and still less in the medulla oblongata. 

"5th. That it seems that, in some men, the sensitive and voluntary motor 
nerve-fibres do not decussate at their usual place, and that, in consequence, 
some rare cases may exist in which an alteration in one side of the pons Varolii, 
or of the medulla oblongata, will produce paralysis of the same side of the 
body. 

" 6th. That there appears to be, in many places of the encephalon, nerve- 
fibres which are not voluntary motor, and which, nevertheless, go to muscles 
either on the same side of the body as that of the encephalon from which they 
originate, or on the opposite side, and that these muscular nerve-fibres are able 
to produce convulsions when they are irritated by an injury or an alteration in 
the encephalon, so that convulsions may take place either on the paralyzed side 
or on the other. 

"7th. The results of the researches of Dr. Ludwig Tiirck cannot, in the 
actual state of science, prove against or in favour of any doctrine relative to the 
place of decussation of sensitive and voluntary nerve-fibres.'' 

As this most interesting work of Dr. Sequard may not fall into the hands of 
a number of our subscribers, we have endeavoured to give them a pretty full 
account of the results to which the author has been led by his researches on the 
physiology and pathology of the spinal cord and other portions of the nervous 
centres. Though in opposition to generally received opinions, their import- 
ance, and the close and logical manner in which the investigations upon which 
they are based have been conducted by Dr. S., press strongly upon our atten- 
tion his conclusions in respect to the place of decussation of the sensitive and 
motor nerve-fibres. D. F. C. 



Art. XXIV. — Observations on Yellow Fever, and its Relations to Quarantine 
and other Hygienic Measures. By S. L. Grier, M. D. 8vo. pp. 41. New 
Orleans, 1854. 

In" relation to many questions, medical opinion would appear to move not 
forward, but in a circle, and hence we have the constant recurrence of doc- 
trines which were once current for a period, and then repudiated for others of 
perhaps a precisely opposite character. In nothing is this more strikingly 



166 



Bibliographical Notices. 



[July 



shown than in the views entertained in regard to the etiology of yellow fever. 
The doctrine of its invariable importation into Europe and into this country by 
fomites or patients sick of the disease ; of its absolute contagion under all cir- 
cumstances, or its propagation by fomites, or a specific morbid emanation from 
the bodies of the sick, under certain conditions of impurity and elevation of 
temperature in the atmosphere of particular localities, which very generally 
prevailed during the latter portion of the eighteenth century, and which most 
of us supposed now almost entirely abandoned by the leading members of the 
profession both at home and abroad. When we had believed that the opposite 
doctrine of the local origin of the disease, and its non-contagious character, was 
become so clearly established by an overwhelming mass of well-authenticated 
facts as to be very generally received, we find efi'orts being made in more than 
one direction to discredit the latter and revive the former. 

To eff'ect this, and in the train of the old hypothesis to subject us to all the 
expense, discomfort, and folly of a system of rigid quarantine, is the object of 
the publication before us. 

Dr. Grier maintains that the yellow fever is not of American origin ; that its 
source can be traced to the eastern continent, in the same manner that we 
trace epidemic cholera to its nativity in remote India. He admits, neverthe- 
less, that it is now naturalized or endemic in certain parts of inter-tropical 
America. The exact limits of this yellow fever zone, north and south, have, 
however, not yet been determined. 

Dr. G. believes it possible for the yellow fever to prevail in New Orleans 
either sporadically, that is, as *' an occasional disease, occurring without any 
general or prevailing cause or endemically, that is, as a disease peculiar to 
the inhabitants of the place — a disease native to the locality ; or epidemically, 
that is, as a disease which, although prevalent among the inhabitants of a city 
or country, is not necessarily native in that locality, and may be extended to 
other places either neighbouring or remote. 

Dr. G. would seem to make a distinction, not in the cause or the more general 
difi'usion of the cause, between yellow fever as an endemic and yellow fever as 
an epidemic, but in the very nature of the disease itself. Thus, while he admits 
that by naturalization it has become endemic in — in other words, a disease of 
New Orleans and other American cities, yet he asserts that 

"Yellow fever, in its epidemic form, does not originate in the cities of the 
United States where it has hitherto prevailed, but has ahcays been introduced 
either in the hold of vessels coming from infected ports, in goods, or by sub- 
jects of the disease. 

" The epidemic virus thus conveyed to our shores is not extended and diffused 
through the medium of the atmosphere, except to a very limited extent, differ- 
ing in this respect from a class of epidemics of which infiuenza may be offered 
as an example, but that it is more allied in its mode of propagation and man- 
ner of progression to another class of epidemics which are known to be conta- 
gious in their character, of which class scarlet fever may be cited as an in- 
stance.'' 

Dr. G. includes yellow fever in that class of contagious diseases '* which are 
transmitted from the sick to the well through the medium of the atmosphere 
immediately surrounding the patient, but only under certain conditions, by 
virtue of which the atmosphere is rendered more liable to be the conductor of 
the specific virus." 

These " certain conditions" are high ranges of temperature, and that form of 
malaria produced by undue moisture, marsh efiluvia, filth, defective ventilation, 
and over-crowded population. None or all of those conditions, however, are, 
according to Dr. G., capable of producing the yellow fever. The combination 
of a foreign or external cause — the virus of the disease — with these local condi- 
tions is, he maintains, essential to its production and propagation. Hence he 
maintains that yellow fever, as an epidemic, is an imported disease — "the 
foreign element which is prerequisite to its production being brought to our 
shores by the ships of commerce, but is incapable of engendering the disease 
in this form unless the domestic conditions necessary to the propagation of an 
epidemic influence are present also." 



1855.] 



Grier, YelJoiu Femere. 



167 



Xow, unless Dr. G. supposes that there are t\vo distinct forms of yellow 
fever, the endemic and the epidemic, he has admitted too much for the safety 
of his unqualified dictum that epidemic yellow fever has always been intro- 
duced from without into every city of the United States where it has hitherto 
prevailed. In certain of these cities he informs us that the disease may occur 
either sporadically or as an endemic ; what, then, according to his own show- 
ing, is to prevent the disease from prevailing epidemically whenever the ma- 
laria, the heat, and the other local elements necessary to the propagation of an 
epidemic influence, are present also? 

We shall not adduce, in refutation of the unqualified dictum of Dr. G. of the 
invariable importation of yellow fever into the United States, the well-authen- 
ticated instances of the occurrence of the disease in our midst, in years when 
no vessel had arrived, for many months previously, from any port at which the 
disease prevailed, nor the numerous instances in which the disease has broken 
out on board of vessels in the midst of the ocean, thousands of miles from land 
— vessels that had sailed from a healthy port, with a healthy crew ; nor still, 
the fact that neither the most rigid seclusion nor the most rigorous quarantine 
has always afforded protection against the disease, while, in some instances, it 
would appear to have increased the certainty of an attack : we shall not ad- 
duce these facts, because Dr. G. may be inclined to answer them by asserting 
that in neither of the circumstances referred to was the yellow fever epidemic, 
and reminding us that the views he has advanced have relation solely to the 
disease in its epidemic form. 

Dr. G. has presented a show of evidence in support of his opinions, of which 
it is not our intention, on the present occasion, to enter into an examination. 
All of it having a direct bearing upon the leading points discussed in the essay 
before us, has been carefully weighed by those fully competent to the task, 
and shown to be altogether inadequate to sustain either the importation of yel- 
low fever or its propagation by contagion. 

By the General Board of Health of Great Britain, all the facts connected with 
the origin and propagation of yellow fever have been carefully examined and 
collated. The conclusion at which the Board have arrived, and which they 
announced to Parliament in their second report, is — 

" That there is no evidence to prove that yellow fever has ever been imported. 

" That, consequently, the means of protection from the disease are not qua- 
rantine restrictions and sanitary cordons, but sanitary works and operations, 
having for their object the removal and prevention of the several localizing 
conditions, and when such permanent works are impracticable, the temporary 
removal, as far as may be possible, of the population from the infected locali- 
ties."' 

"When we reflect that those conclusions are drawn not from a few isolated 
facts, but from a mass of testimony extending through the history of the yel- 
low fever from 1793 to 1851, and derived from the most impartial observers 
who had ample opportunities of investigating every point connected with the 
etiology of the disease, we cannot but acknowledge their force ; more espe- 
cially, when such men as Edwin Chadwick and T. Southwood Smith, by whom 
the report alluded to was drawn up, assure us — 

" That from the most careful examination which we have been able to make 
of the mass of evidence submitted to us, from which the foregoing conclusions 
have been deduced, we have not found a single fact or obser-vaiion clearly ascer- 
tained, and authentically recorded, opposed to the general tenor of such evidence. 
We have met with no exceptional cases. We have, indeed, found the opinions 
of some authorities, for whom we entertain great respect, not in accordance on 
some points ; but these have reference, for the most part, to matters of a purely 
professional and scientific nature. On the great practical question, whether, 
whatever may be the nature and mode of propagation of yellow fever, quaran- 
tine and sanitary cordons can afford any real protection against its introduction 
and spread, we believe there is now a very general unanimity of opinion that, 
in accordance with the evidence we have submitted, they cannot. We believe 
there is the like general agreement in this further practical conclusion, that 
the substitution of sanitary or hygienic measures for quarantine isolation and 
restriction, would afford more certain and effectual protection.'"-' D. F. C. 



168 



BlhUogrrijjJiical Xotices. 



[July 



Art. XXV. — Illustrated Manual of Operative Surgery and Surgical Anatomy. — 
By MM. C. Bernard, D. M. P., and Ch, Huette. Edited, with notes and ad- 
ditions, and adapted to the use of the American Medical Student, by W, H. Tax 
BuREX, M. D., Prof, of Anatomy, University Medical College, and Surgeon 
to Xew York Hospital, and C. E. Isaacs, M. D., Demonstrator of Anatomy, 
Univ. Med. Coll., and Consulting Surgeon to the Penitentiary Hospital, 
Blackwell's Island, illustrated v:ith steel engravings from drawings after 
nature, by ]M. J. Leveille. Designed to serve as a companion to the ordinan/ 
text-books of Surgery. New York: H. Bailliere, 290 Broadway, 1855. 113 
plates, and 513 pages. 

The first half of this well-known and popular manual has been already three 
years before the profession, and was duly recommended to the notice of our 
readers in 1852, TTe take great pleasure in announcing the long looked-for 
publication of the remaining parts, and in. expressing our admiration of the 
whole work in its present complete and elegant form. It is unquestionably the 
handsomest compendium of Operative Surgery that has yet appeared; and, 
withal, so compactly as well as clearly and comprehensively arranged, that 
we are inclined to think that it may prove even more useful than it is orna- 
mental. The American editors have good reason to congratulate themselves 
on having successfully supplied a want which has hitherto continued to be 
felt, in presenting the beautiful and accurate illustrations and methodical ac- 
companying text of MM. Bernard and Huette, as *' a complete and concise 
picture of the science and art of Operative Surgery, in its present advanced 
and perfected condition, in a portable form." 

They do not place their translation in competition with the great work of 
Bourgery and Jacob, or with the American edition of Yelpeau, or the quarto 
of Prof, Pancoast. "We would decidedly prefer it to either of these (except the 
first, which is altogether out of general reach), as much more recent, and, for 
most practical purposes, both more available and more reliable in the hands of 
the student or inexperienced practitioner. "Its compactness and portability 
will render it," as they justly say, "more desirable to the student as a com- 
panion in the lecture and dissecting-room, where its copious and graphic illus- 
trations will assist him materially in acquiring correct general ideas as to the 
nature and objects of the individual operations of surgery ; whilst for more 
minute and varied details with regard to their history and numerous modifica- 
tions, the less accessible and more expensive treatises alluded to can be con- 
sulted at a more advanced period of study," "Our manual," they further 
intimate, "whilst it is intended mainly to illustrate the intricacies of operative 
surgery hj appealing to the eye as well as to the understanding of the student, 
and by familiarizing him with that most useful department of anatomy which 
immediately relates to surgical operations, will also be found, it is hoped, not 
entirelv useless as a work of reference to those already engaged in practice." — 
{R Q of Preface.) 

The first twenty-five plates are preliminary, and present, in a large number 
of remarkably well-executed and colored figures, all the most approved instru- 
ments required in surgical operations. These instruments appear to have been 
selected with discriminating care, although in great abundance and variety. 
As a matter of course, they are mostly French, and after the patterns of Char- 
riere. 

X'ext in order come six other plates, also introductory in character, occupied 
with the usual minor or elementary operations ; such as the positions of the 
bistoury, incisions, union of wounds, seton, venesection, arteriotomy, ligature 
of arteries, and other manipulations of this class. 

These are followed by an admirable series of illustrations of the surgical 
anatomy and operative surgery, side by side, of the ligature of the different 
arteries. This important subject is here presented in ten plates and some 
thirty figures, which are not excelled in beauty, accuracy, and practical value 
by any in the book. 



1855.] 



Bernard and Huette, Operative Surgery^ etc. 



169 



Amputations through the joints, in the continuity of limbs, exsections, and 
trepanning are severally and successively exhibited in the eighteen subsequent 
plates ; ample demonstrations of the surgical anatomy accompanying, through- 
out, the delineations of the critical stages of each operative procedure. These 
are succeeded by attractive representations of a great variety of delicate ope- 
rations on different organs and regions of the body, which we have not room to 
specify. Among them we may note especially those upon the eye, upon the 
ear and other portions of the head, and upon the throat, neck, chest, and 
abdomen. 

Then we have the management of abdominal and intestinal wounds, the sur- 
gical and pathological anatomy and surgery of hernia and of artificial anus, 
and the operations upon the anus and rectum. Plates 60, 61, 62, and 64, on 
the anatomy of hernia, are in every point of view deserving of particular 
attention. TTere it possible to select, from the great number of rich and appro- 
priate engravings, three, or four, or half a dozen that might be regarded as 
embodying and portraying the distinctive excellences of the whole work, we 
would be disposed to point to these pictures of hernia. They are masterpieces 
of their kind, if not decidedly the best specimens of miniature illustration that 
MM, Bernard and Huette, or any others, have produced. 

The remainder of the volume is taken up with operations on the male genito- 
urinary organs, including those for stricture and its consequences, and for uri- 
nary calcuU; with operations on the female genital organs, and, lastly, with 
tenotomy. 

The foregoing brief sketch and outline of its principal contents will afford a 
faint idea of the character and value of the book before us. The standing of 
the French original, as that of the most convenient and attractive elementary 
atlas extant of operative surgery, while it is inferior to none in the fidelity of 
its teaching, has been so long established that we are spared the necessity of 
dwelling on it here. It is justly regarded by a Parisian authority as "at once 
a work of science and a work of art.-" " Science," says this writer, "is exem- 
plified in its perfect acquaintance with surgical anatomy, and above ail in its 
methodical exposition and judicious choice of the innumerable procedures of 
operative medicine ; whilst art shines in each plate with a characteristic grace 
and finish which in no way impair the exactness of its details." — [Archives 
Generales, 1855, p. 383.) 

The engravings of the American edition are evidently duplicates of the ori- 
ginal copies, and hence identical with them in artistic superiority. The letter 
press is, as already intimated, well arranged, clear, concise, and sufficiently 
full for the purpose intended. It appears to have been faithfully and elegantly 
translated; and, according to the promise of the editors, is agreeably free from 
idiomatic and un-American phrases and technicalities. It cannot fail, there- 
fore, to be sought after by intelligent students as a cherished adjunct to the 
various text-books of the schools ; and will be no less likely to afford, even to 
teachers and practitioners, an amount of aid and comfort that cannot be hoped 
for from any other work of similar character. 

The additions of the editors, which are most unobtrusively appended, are 
judicious and appropriate. Although not very numerous or lengthy, some of 
them are important in connection with American practice ; and all are inte- 
resting, and such as decidedly add to the value of the work without interfer- 
ing with the previous context, or perceptibly increasing the size of the volume. 
The publishers have been equally successful in the paper and printing, and 
the general getting up ; so that we may venture to presume that their trans- 
atlantic confreres will have no reason to be ashamed of the American reprint. 
With the best wishes for the success of a publication which does the highest 
honour to the good taste, enterprise, and judgment of all concerned, we most 
cordially recommend it as on all accounts worthy of a prominent place in every 
medical library, or on every office table. E. H. 



170 



BibUograpliical Notices. 



[July 



Art. XXVI. — The Pathology and Treatment of Leucorrhoea. By W. Tyler 
Smith, M. D., Member of the Royal College of Physicians, Physican Accou- 
cheur to St. Mary's Hospital ; Lecturer on Midwifery and the Diseases of 
Women, in St. Mary's Hospital Medical School ; Vice-President of the Me- 
dical Society of London; Honorary Fellow of the Obstetrical Society of Dub- 
lin, etc. etc. 8vo. pp. 199. Philadelphia, 1855 : Blanchard & Lea. 

There is great truth in the remarks with which Dr. Smith commences the 
present treatise, which is to be viewed as the more full development of the 
leading points in reference to leucorrhoea and its allied disorders, advanced in 
a memoir presented by the author to the Royal Medical and Chirurgical Society 
of London, and published in the thirty-fifth volume of its Transactions. 

"Few topics, '^ he very justly observes, "have been more discussed, during 
recent years, than those relating to the pathology and treatment of disorders of 
the uterine organs attended by discharges. But it must be confessed that 
discussion has expended itself chiefly upon verbal criticism, and contributed 
little towards the more clear comprehension of this department of medicine, 
there has been much of argument, but, as I submit, little of rigorous exami- 
nation. Tongue and pen have been plied with remarkable assiduity, yet the 
difficulties surrounding the subject have been rather increased than diminished. 
On many points of diagnosis and pathology, apparently the most simple and 
easy of solution, the greatest uncertainty still prevails. This uncertainty na- 
turally extends itself to the subject of treatment, and shows itself at every turn 
in practice. The various lesions, real and supposed, of the os and cervix uteri — 
ulceration, induration, and inflammation — have been attacked or defended by 
their partisans and opponents with the hottest zeal. In the diagnosis of these 
affections, some have practised instrumental examinations to an extent hitherto 
unprecedented in this country, while others have condemned such examinations 
altogether. As regards treatment, we see at one time injections, at another 
pessaries, at another cauterizations, are assailed with the utmost vigour, leav- 
ing the conscientious practitioner bewildered and uncertain as to what are really 
the best methods of controlling the confessedly troublesome and prevalent 
maladies, for which these and other appliances are in turn vaunted or anathe- 
matized." 

To acquire, if possible, more correct and definite views in regard to the 
pathology and proper treatment of a class of diseases, of the character and 
management of which, though much has been said and written, little is actually 
known. Dr. Smith, aided by the microscope, has investigated anew the nature 
and structure of the several tissues of the vagina and os and cervix uteri, the 
secretions of these parts in the healthy state, and their several morbid condi- 
tions, from that attended by a simple augmentation of the normal secretions, 
onward, through the several stages of abrasion and simple ulceration of the 
vagina, and of inflammation, abrasion, ulceration, induration, and hypertrophy 
of the mouth and neck of the uterus. 

This investigation is one replete with interest, and has been conducted in a 
systematic and skilful manner by Dr. Smith. Although the correctness of some 
of the positions laid down by him may admit of dispute, he has nevertheless 
succeeded in furnishing the foundations for a more correct pathology of leu- 
corrhoea than has hitherto existed, and for a more rational and successful 
treatment of the several morbid conditions of the uterus and vagina, in con- 
nection with which leucorrhoeal discharges are liable to occur. 

" If, as I have previously shown," says Dr. S., " great discrepancy of opinion 
has prevailed respecting the sources of the healthy secretions of the vagina and 
canal of the cervix uteri, there has been still greater confusion as regards the 
seat and constitution of the morbid utero-vaginal discharges. No one had 
inquired minutely into the nature of these discharges, so that current opinions 
upon the subject have had no better foundation than guessing and hypothesis. 
Let any one who doubts the correctness of what is here advanced, examine for 
himself the doctrines hitherto taught respecting leucorrhoea, and he will find 



1855.] 



W. Tyler Smithy Leucorrlicea. 



171 



that some refer to the TulTO-vaginal glands as the chief seat of leucorrhceal 
discharges : that others refer to the vagina as a great follicular tract from which 
the principal amount of these discharges proceeds ; that others, again, look to the 
cavity of the fundus uteri and its mucous lining as the great source of uterine 
mucous secretions. As regards the causes of these discharges, some have 
limited their attention to the sexual organs, while others have looked to the 
conditions of remote parts of the body, for the explanation of leucorrhceal dis- 
orders. It vrould, indeed, be easy to fill a volume with the discordant accounts 
which, in the absence of a knowledge of the minute anatomy of the parts in- 
volved, have been given of the nature and source of leucorrhceal discharges. 
One or two authors only have referred to the canal of the cervix uteri as the 
principal seat of mischief in leucorrhcea ; but their teachings have been un- 
certain and without proof, since no one, so far as I am aware, ever made a 
positive and minute examination into the subject, or recognized to the full 
extent the glandular organization of the cervical canal. Xo pathologist has 
hitherto formed anything like a just appreciation of the parts borne re- 
spectively by the vagina and the os and cervix uteri in the production of leu- 
corrhceal discharges. Effects have been constantly mistaken for causes, and 
secondary phenomena have received the importance due to those which are 
primary, while in practice the most important structures have frequently 
escaped attention altogether. The consequence has been that some have re- 
commended the most violent measures of treatment, while others have rejected 
all remedial measures except the most simple and inert. Meanwhile, this de- 
partment of medicine has witnessed a contest which for virulence and acrimony 
has seldom been equalled in the profession." 

According to the researches of Dr. S., the mucus secreted by the glands of 
the ostium vaginae, in the absence of excitement, is so inconsiderable, or is so 
mixed up with the scaly epithelium of the mucous surface of this part, that 
it is excremely difficult to ascertain precisely its microscopical qualities. In 
some women, a profuse emission of fluid appears to take place from these 
glands during sexual intercourse. Like the other vaginal secretions, this mucus 
has an acid reaction. 

" The mucus of the vaginal canal is not found in any considerable quantity 
in the healthy subject; it is only secreted in sufficient quantity to keep the 
mucous surface in a state of lubrication. It lies upon the mucous membrane 
as a milky fluid, containing small curdy points or masses, and consists of a 
transparent or semi-transparent plasma, containing an abundance of scaly 
epithelium and its debris.'' " The plasma of the vaginal mucus appears, when 
first secreted, to resemble the plasma of the cervical mucus ; but it is less viscid 
and tenacious. It is only after it has lain a short time upon the vaginal sur- 
face that it becomes curdled. The vaginal mucus is, as M. Donne first remarked, 
distinctly acid, and it is to the effect of the acid in coagulating the albumen of 
the mucus, and not to the presence of epithelium, that its curdled appearance 
is attributable." 

" As regards secretion, the vagina is always pretty much in the same con- 
dition, except that the acidity is constantly increased during pregnancy ; but 
the cervix uteri has to pass through various physiological changes during the 
performance of the functions of menstruation, pregnancy, parturition, and lac- 
tation. It becomes necessary, therefore, to consider the secretion of the canal 
of the cervix in these several states. 

" In the unimpregnated condition, when the cervix uteri is found perfectly 
healthy, little or no discharge is seen issuing from the cervical cavity ; but when 
the labia uteri are separated, the canal of the cervix appears to be full of its 
peculiar secretion. In examinations after death, in cases in which the uterine 
organs are in a healthy condition, the mucous crypts and the canal of the cervix 
are generally found filled with a clear, viscid mucus, so as to entirely block up 
the passage from the vagina to the cavity of the fundus. This appears to be 
the normal condition of the cervical canal, in the unimpregnated state. At 
each catamenial period, the whole of the tenacious plug of mucus must be 
washed away by the menstrual fluid, as the latter may be seen escaping freely 
from the os uteri at these times ; but, in a few days after the completion of the 



172 



BibliograpMcal Notices. 



[July 



period, the mucous plug is again formed. When first secreted, the cervical 
mucus is less thick and viscid than it afterwards becomes. Thus, it would seem 
to be the function of the glandular structure of the cervix, in the unimpreg- 
nated uterus, to secrete, each month, a sufficient quantity of viscid mucus to fill 
the canal of the cervix, the mucous follicles becoming comparatively inactive 
when this has been accomplished, until after its removal at the next flow of 
the catamenia. The function of the cervix is, therefore, in a certain sense, like 
that of the fundus, periodical; and we shall see hereafter that this periodicity 
is discernable in the diseased conditions of the cervix and its secretions. In 
healthy subjects, the canal of the cervix is always full in the intervals between 
the menstrual periods, though there certainly seems nothing like a constant 
flow of the cervical mucus into the vagina. Just enough is secreted to fill the 
canal. The mucus itself consists of myriads of mucus-corpuscles entangled in 
a transparent viscid plasma. The plasma is so tenacious that the mucus-cor- 
puscles are found to be arranged in strings when placed under the microscope, 
and individual corpuscles are frequently seen to be elongated from the same 
cause. 

" The use of the cervical mucus is probably twofold. In the first place, it 
closes the cervix uteri, and defends the cavity of the fundus from external agen- 
cies as completely as though it were a shut sac. In the second place, it appears 
to afi"ord a suitable medium for the passage of the spermatozoa through the 
cervix uteri into the uterine cavity.'' 

" After the commencement of pregnane?/, the periodical functions of the uterus 
cease, and, in the generality of cases, the plug of viscid mucus, when it is once 
formed, continues for the most unremoved until the commencement of labour." 
" Generally, during gestation, the lowest part of the plug is to a slight extent 
constantly wearing away, and is discharged in the form of debris into the vagina; 
but the secretion from the cervix goes on only to such an extent as to keep the 
03 and cervix closed. In other cases, the secretion is more profuse, but the 
cervix is still kept full by an increased secretion from the glandular structures. 
The mucous plug formed during pregnancy is firmer than the mucus filling 
the cervix in the intervals between the monthly periods in the unimpregnated 
state, particularly at its lowest part, where it is perfectly white and opaque. 
In the upper parts of the cervix, it is clear and transparent. The plug con- 
sists, in the upper part of the cervix, entirely of mucous globules and plasma ; 
but in the lower portions of the plug these elements are mixed with scaly epi- 
thelium in considerable quantity.'' 

During pm^turitionf the canal of the cervix secretes a quantity of mucus hav- 
ing a more fluid character than the plug of pregnancy. This secretion con- 
tinues throughout the act of parturition. The os uteri and vagina are freely 
lubricated by it. 

" It has been generally considered," remarks Dr. S., **a vaginal secretion, 
partly from the fact of its being found upon the vaginal surface, and partly 
because no minute inquiry into its nature has ever been made. There is, how- 
ever, no evidence that the vagina secretes much more profusely during labour 
than at any other time, and there could hardly be a profuse secretion from the 
vaginal mucous surface without such a shedding of epithelium as would leave 
the subjacent structures irritable and painful. Microscopical examination 
proves that the mucus found in the vagina is chiefly the product of the glands 
of the cervical canal. At the commencement of labour, the discharge is white 
and opaque ; but as labour proceeds, and after the plug of pregnancy has 
escaped, it becomes clear and transparent. It is now of the consistence of 
white of egg, alkaline in character, and consists almost entirely of tenacious 
plasma and an immense quantity of mucous globules, intermixed with scaly 
epithelium." 

" Upon the completion of natural labour, these glands — those of the cervix 
uteri — continue to secrete with considerable activity, and their secretion forms 
a part of the lochial discharge. In many cases, the last secretion which appears 
after the cessation of the lochia, is the viscid secretion of the canal of the 
cervix. Thus it is, perhaps, during parturition that the glandular function of 
the canal of the cervix uteri is most actively performed. The glandular element 



1855.] W. Tyler Smith, on Leucorrhoea. 173 

seems of more importance, at this time, than either in the unimpregnated state 
of the uterus or during the course of pregnancy. The uses of the secretion in 
lubricating the os and cervix uteri and the vagina, during labour, are suffi- 
ciently obvious. The physiological condition which obtains at this time is 
also very closely allied to the pathological conditions which are present in the 
most common forms of leucorrhcea. 

*' Mild leucorrhoeal discharge is very common during the period of suckling, 
particularly in women who do not menstruate. The secretion takes place, I 
have no doubt, chiefly from the glands of the cervical canal. In some cases, 
it is constant ; in others, it occurs only at the monthly periods. It is a common 
observation that, after labour, the application of the child to the breast causes 
after-pains, and an increase of the lochial discharge. Uterine contraction and 
uterine pain are caused, for several days after delivery, every time the child is 
put to the breast, or the sensation of the draught is experienced. But it occa- 
sionally happens that this intimate relation between the breasts and the uterus 
is preserved to some extent during the whole of lactation, and I have met with 
some cases in which cervical leucorrhoeal discharge constantly occurred when- 
ever the child sucked the breast. Thus there is a marked tendency to increased 
secretion from the glands of the cervical canal during lactation. Sometimes 
the foundation of chronic leucorrhoea is laid at this time ; but the increased 
mucous secretion generally ceases after weaning, and the re-establishment of 
menstruation. In women who are drained largely by leucorrhoeal discharges, 
while nursing, it is only necessary to direct them to wean the child, and the 
discharge speedily diminishes.'^ 

We have given the foregoing general description of the normal secretions of 
the vagina and neck of the uterus, as laid down by Dr. S., because the views of 
that gentleman in relation to the pathology of leucorrhoea could not be well un- 
derstood without it. His account of the secretions diflFers, in many particulars, 
from that commonly received; it would appear, however, to be based upon a 
series of accurate observations, and is, in all probability, correct. 

Dr. S. divides leucorrhoea into two leading varieties, cervical or mucous leu- 
corrhoea, and vaginal or epithelial leucorrhoea. 

" It may be well," he observes, " to revert, for a moment, to the special 
differences which exist between the vagina and the cervical canal. The lining 
membrane of the vagina approaches in organization to the skin ; it is covered 
by a thick layer of scaly epithelium ; in contains in the greater part of its sur- 
face few, if any, mucous follicles or glands ; its secretion is acid, consisting 
entirely of plasma and epithelium, and the chief object of the secretion is the 
lubrication of the surface upon which it is formed. On the other hand, the 
lining of the canal of the cervix is a true mucous membrane; it is covered, in 
great part, by cylinder epithelium ; it abounds with immense numbers of mu- 
cous follicles having a special arrangement ; it pours forth a true mucous 
secretion, alkaline in character, and consisting of mucous corpuscles and 
plasma, with little or no epithelium ; and this secretion has special uses to 
perform in the unimpregnated state, and in pregnancy and parturition. Leu- 
corrhoea admits of a similar division. The first, and the most frequent and 
important, is the mucous variety, consisting chiefly of mucous corpuscles and 
plasma, and secreted chiefly by the follicular canal of the cervix. The second 
is the epithelial variety, in which the discharge is vaginal, or is secreted by the 
vaginal portion of the os and cervix, and consists, for the most part, of scaly 
epithelium and its debris. These two varieties may, of course, exist in various 
degrees of combination ; sometimes the one and sometimes the other preponde- 
rates, or is the original affection ; but the chief importance must be given to 
cervical or mucous leucorrhoea, as being the most obstinate and common.''^ 

Mucous leucorrhoea, when simple and uncomplicated, is the result of a mor- 
bid activity of the glandular cervix. The discharge is at first nothing more 
than an unusual amount of the elements found in the healthy mucus of the 
cervical canal. In very severe cases, the mucus of the cervix becomes mixed 
with pus corpuscles, and the discharge is rendered muco-purulent in character, 
or the surface of the canal and the os uteri becomes so irritable as to bleed on 
the slightest irritation, blood corpuscles being added as another element of the 
No. LIX.— July 1855. 12 



174 BibliograpTiical Notices. [July 

discharge. When the quantity of blood is large and speedily evacuated from 
the vagina, the discharge resembles the menstrual flux in colour; but when 
small in quantity and evacuated slowly, it gives to the discharge a greenish or 
brownish tint. When in cases of simple leucorrhoea the discharge is profuse 
and long continued, it often proves a serious drain to the constitution, and gives 
rise to functional or more serious disorders in different parts of the body. In 
other cases, the secretion is so profuse and watery that the traces of viscidity 
are nearly lost. This excessive watery secretion, when long continued, is a 
source not only of inconvenience, but of great debility. Patients suffering 
from cervical leucorrhoea, besides becoming extremely debilitated by the amount 
of the discharge, may, also, become hectic from purulent secretion and absorp- 
tion, or they may be rendered anaemic by the sanguineous complication. In the 
worst cases, the discharges, in their physical appearances, may resemble those 
in carcinoma. 

" The discharge in vaginal leucorrlicea may arise, chiefly, either from the 
lower portion of the vaginal membrane, or from that part which is reflected over 
the cervix; but in severe cases, the whole surface of the vagina is involved. 
The secretion, in these cases, generally consists entirely of epithelium, in every 
possible phase of development, mixed with acid mucous plasma.'' " If the case 
be acute, there are no old and broken scales, such as are found in the healthy 
secretion, the epithelium being separated too rapidly, in the formation and flow 
of the discharge, to admit of their coming to maturity and wearing away in the 
vagina. In mild cases, when the separation is more slow, ripe and well worn 
scales are sometimes present. When the vaginal form of leucorrhoea becomes 
very severe, the villi become affected, and not only is epithelium separated with 
extraordinary rapidity, but pus is formed upon the irritable sub-epithelial or 
villous surface, which, when mixed with the epithelial matter, can hardly be 
distinguished from the mucous corpuscles of the cervix, mixed with scaly epi- 
thelium. The state of the vagina, as seen by the eye, will, however, remove all 
doubt as to the nature of the discharge in these cases. A further complication 
of vaginal leucorrhoea may occur, as when portions of the vaginal surface are 
so abraded that blood-globules escape and mix with the other constituents of the 
vaginal discharge. The vaginal secretions now described are those most com- 
monly found in vaginal or epithelial leucorrhoea ; but there is another form of 
vaginal discharge which deserves consideration." In this, "the epithelium is 
thrown off in large shreds or pieces, in which the pavement-like arrangement 
of the scales is perfectly preserved. These laminae frequently have upon them 
marks of the rugee of the vagina, and somewhat resemble the cuticle in cases of 
acute desquamation of the surf;.ice of the body. The under surfaces of these 
masses are also rough from the indentations of the vaginal papillae. Sometimes, 
on making a specular examination in these cases, the whole surface of the va- 
gina is seen covered with a white coating, which may be removed by a forceps 
in membranous pieces of considerable extent and thickness. This affection may 
be attended with a slight discharge from the sub-epithelial surface ; but in many 
cases the vagina does not contain more secretion than usual, or it may be un- 
naturally dry. In all epithelial affections of the vagina, the discharge is acid ; 
but the acidity is particularly marked in this — the membranous form of leucor- 
rhoea, as it may be termed. Some of the instances in which I have seen this 
affection in its most marked form, have been in cases of pregnancy. I have 
■sometimes had patients bring me a mass as large as a walnut, consisting of 
pieces of the epithelial coat of the vagina rolled up like paper ; or I have seen 
a tumblerful of water rendered perfectly thick with the quantity of shreds 
removed from the vagina by a single injection. 

"In these cases, the simple shedding of the epithelium in great abundance, 
and the desquamation of the epithelium in masses, might be called Epiilielial 
Vaginitis, while the purulent form of the disorder, in which the villi are 
affected, might be called Villous Vaginitis.'" 

So much for the simple forms of leucorrhoea; its sequelae, when allowed to 
continue unchecked, are, according to Dr. S., inflammation, abrasion, ulcera- 
tion, and hypertrophy of the os and cervix uteri, and abrasion and superficial 
ulceration of the vagina. It is the conviction of Dr. S. that, in the majority of 



1855.] 



W. Tyler Smitli, on Leucorrhoea. 



175 



those diseased conditions of the os and cervix uteri, which have of late been 
assigned so prominent a rank as distinct and independent affections in medical 
discussions, are in the majority of cases secondary affections, cervical leucor- 
rhoea being, in fact, the primary and most essential disease. In maintaining 
the important part played by the cervical secretions in inducing morbid condi- 
tions of the OS uteri, he does not v^^ish, however, to be understood as saying 
that they are the only causes of these conditions. But even when disease of 
the OS and cervix uteri has been induced by other causes, cervical leucorrhoea 
is almost invariably produced, and it generally tends to aggravate the diseased 
condition of those parts. 

Each of the conditions referred to by the author as sequelae of leucorrhoea 
are separately considered. The extent to which we have already been led in 
our quotations from the work before us, admonishes us of the necessity of pass- 
ing, over the interesting remarks presented in reference to these sequelae. 

The constitutional and other derangements consequent upon protracted leu- 
corrhoea come next under consideration. They are general debility, stomachic 
derangement, amenorrhoea or uterine hemorrhage, angemia, hectic fever, de- 
rangements of the nervous system, pains in various parts of the body, neuralgic 
affections of the neck of the uterus, and troublesome affections of the bladder 
and rectum. 

The diagnosis between leucorrhoea and cancer uteri, the relations between 
secondary syphilis and leucorrhoea, are then separately discussed, and a most 
interesting chapter is given on the relations of vaginal leucorrhoea to gonor- 
rhoea in the female, urethritis in the male, and the ophthalmia of new-born 
infants. 

Dr. S. believes gonorrhoea in the female to be closely allied to vaginal leucor- 
rhoea, and hence impure connection may be ranked as one of the causes of the 
latter. He has no doubt, also, that urethritis and inflammation of the glans 
penis may be induced in the male by a female labouring under spontaneous 
leucorrhoea arising independently of sexual intercourse, and that ophthalmia 
neonatorum may be caused in children born of females labouring under non- 
gonorrhoeal leucorrhoea. 

In Chapter IX., the author discusses the relations of leucorrhoea to disorders 
of the function of menstruation. He remarks that it is very rarely that leucor- 
rhoea, with diseased conditions of the lower segment of the uterus, exists for 
any length of time without inducing some disorder of the catamenial function. 
This occurs chiefly in the cervical forms of leucorrhoea, or those- cases of vagi- 
nal leucorrhoea in which the affection is confined to the surface of the os uteri 
and vaginal portion of the cervix. In some cases, the leucorrhoeal affection is 
the secondary disease, amenorrhoea, menorrhagia, or dysmenorrhoea having 
preceded it ; but most commonly, according to Dr. S., the former is found to be 
the primary disorder in these cases, and the catamenial derangement has 
slowly followed upon chronic leucorrhoea. 

Periodical leucorrhoea, or leucorrhoea vicarious to menstruation, receives a 
passing notice, and in the ensuing chapter (X.) the relations of leucorrhoea to 
sterility and abortion are very fully considered, which closes the discussion of 
the pathological character and relations of the disease. 

As constitutional local causes of the disease. Dr. S. enumerates plethora, 
debility, prolonged lactation, the strumous habit, skin diseases, climate, rectal, 
vesical, urethral, vaginal, and uterine irritation, gestation, abortion, and labour. 
Appended to the chapter are some remarks on leucorrhoea in children. 

At the risk of being accused of extending this notice to an unwarrantable 
length, we cannot refrain from presenting to our readers the concluding para- 
graph of this chapter of the work. It presents a general summary of the 
author's views in regard to the nature of leucorrhoea, and an expression of his 
opinion on a question of uterine pathology warmly discussed at the present 
period. 

" From the whole tenor of the present work,'^ says Dr. S., " it will be seen 
that I differ very strongly from the opinions which refer almost all the condi- 
tions upon which leucorrhoea depends to inflammation of the os and cervix 
uteri. I believe it cannot now be disputed that many of the affections of the 



176 



Bibliographical Notices. 



[July 



OS and cervix recently stated to constitute ulceration of the surface, are, in 
reality, only epithelial abrasions of more or less completeness. As regards 
ulceration, I believe the more searching examinations to which its asserted 
frequency has led, prove that its importance and frequency are much less than 
were formerly asserted. A modified view of the lesions supposed to constitute 
ulceration of the os and cervix uteri must certainly be taken ; and, in a former 
chapter, I have stated the grounds upon which I believe that abrasions and 
superficial ulcerations of the os and cervix uteri, when they occur, are very 
frequently secondary afiections, instead of primary disorders. In like manner, 
I believe the vaunted importance of inflammation, as the great cause of uterine 
disorder, must be altogether modified. I think the term ' epithelial abrasion^ 
should, in the great majority of cases, take the place of ' ulceration and I 
believe that the words 'irritation^ or 'relaxation^ should generally take the 
place which has been assigned to ' inflammation.' The changes in the uterus, 
and the increased secretions of the uterus and vagina, found in cases of leucor- 
rhoea, are not such as attend inflammation in other parts of the body. It is not 
after an attack of acknowledged metritis that leucorrhoea is most prone to 
occur. The discharge generally comes on in so slow a manner that its advent 
cannot often be referred to any particular date. No doubt, in some cases — as 
after suppression of the catamenia from cold or imprudence ; after abortion or 
parturition, or mechanical injury — a genuine inflammatory state lays the 
foundation of leucorrhoea ; but the leucorrhoeal discharge and the local irrita- 
tion constantly remain long after the signs of positive inflammatory disease 
have passed away. Chronic irritation and relaxation, rather than chronic in- 
flammation, is the state which generally obtains under these circumstances. 
The most common and immediate cause of leucorrhoea is simple irritation of 
the glands of the cervical canal, and many of the conditions described as in- 
flammatory, such as abrasions and indurations of the os and cervix uteri, are, 
as I have repeatedly observed, the results of the long continued discharge, 
rather than of any inflammation occurring in the os and cervix as a primary 
affection." 

In the treatment of leucorrhoea. Dr. S. remarks that undue prominence must 
not be given to either constitutional or local medication. In some cases, con- 
stitutional measures alone will be sufficient to arrest the disease ; in others, 
this may be effected by local means ; but, in the great majority of cases, both 
constitutional and local measures will be necessary to effect a permanent cure. 
The general principle of treatment, we are told, must be the arrest of the dis- 
charge, the removal of the local disorder upon which the discharge depends, 
and the relief of any constitutional disorder with which the leucorrhoea may be 
connected, either as cause or effect. 

To fulfil these indications, the remedies noticed by Dr. S. are preparations 
of iron, a combination of iron and alum, tonics, purgatives, vaginal injections, 
caustic application, pessaries, cubebs and matico, etc., bathing, change of air, 
rest, and recumbency. 

The comments of the author upon each of these remedies, and the particular 
circumstances and stages of the disease to which they are respectively adapted, 
are full and interesting. His remarks on the abuse of cauterization are par- 
ticularly opportune. There are too many practitioners who, in almost every 
case of impaired health in the female, diagnose disease of the neck of the 
womb, and, as a necessary consequence, introduce the speculum and make 
repeated applications of the nitrate of silver to ulcers of the cervix uteri, either 
real or imaginary. 

We thank Dr. Smith for his very excellent monograph, and very earnestly 
recommend it to the notice of American practitioners. No one, we are per- 
suaded, can rise from its perusal without having acquired more definite and 
correct views of the pathology of leucorrhoea, and a clearer conception of its 
proper treatment under the several forms, and with the different complications 
• it is liable to occur. D. F. C. 



1855.] 



177 



QUARTERLY SUMMARY 

OF THE 

IMPEOVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. The Entrance of the Spermatozoon into the Ovum. By M. Keber.- — By 
the diligence of embryologists, the science of development continues to make 
wonderful advances. Martin Barry and Nelson had already published ob- 
servations of the entrance of the spermatozoon into the ovulum ; but their 
observations were not regarded as completely satisfactory, till Keber, following 
in their footsteps, by a careful observation of the process as it takes place in 
the fresh water mussel, made out and described the different stages of this 
wonderful function. Since Keber's work appeared, M. Bischoff has been twice 
in the press ; first of all, with a pamphlet controverting the views of Keber, 
and then with one fully confirming the same views. Bischoff also takes occa- 
sion to make some amends to Martin Barry, whose uncommon accuracy and 
profound research he has occasionally failed to recognize, till forced by over- 
powering evidence. 

In the fresh water mussel [unio), at the time of conception, the ovulum, 
although still small, projects at one part a minute process which springs from 
the membrane of the albumen, and perforates the cortical membrane. This 
process dehisces, lets escape a little albumen, and admits one of the spermatozoa 
which surround it. This done, the micropyle, as it is called, again closes by 
constriction or obliteration. 

Afterwards (and sometimes earlier) there is formed near the micropyle an 
adhesion between the membranes of the albumen and of the yelk, then the 
yelk-bag dehisces, receives the spermatozoon into its interior, and again is 
closed. 

The spermatozoon afterwards sinks deep into the yelk, swells and becomes 
rounded ; after some time a nucleus appears in it, while its outer membrane 
thins and at length disappears. 

The nucleus of the spermatozoon splits up into several irregular divisions 
which at first lie near one another, and then become diffused through the yelk, 
so that before the dissolution of the germinal vesicle the yelk is filled with 
particles derived from the male. 

M. Keber has also confirmed the observations of Barry in regard to the small 
pellucid vesicles not rarely found in the abdominal cavity of the rabbit, at- 
tached to the ovary, the fimbri93, the oviduct, the peritoneum, or the uterus 
itself ; within which are observed vibratory motions over the whole surface, and 
rotatory movements of various corpuscles, and of a large mulberry-like body on 
its axis, which increases under the eye of the observer by the apposition to it 
of roundish corpuscles from the fluid of the vesicle. 

Barry observed a similar vesicle imbedded in the mucous membrane of the 



178 



Progress of the Medical Sciences. 



[July 



uterus. Those found in this situation are smaller than those of the abdominal 
cavity. In these bodies, Keberhas observed changes resembling the formation 
of the micropyle in the ovulum, and for that and other reasons regards these 
vesicles as ova. But for further discussion of this subject we refer the reader 
to Keber's monograph. — Edinburgh Med. and Surg. Journ., October, 1854. 

2. Histology of the Betina. — The observations of Gegenbaur, Kolliker, 
Leydig, H. Muller, and Virchow, on the body of a beheaded criminal, though 
chiefly of value in a physiological aspect, throw light on some hitherto obscure 
points in normal histology. 

In some investigations on the retina, it was found that, in the neighbour- 
hood of the yellow spot, the cones are smaller, but of greater length, and closely 
pressed together, while, external to it, the rods become interposed. The cones, 
in this situation, were scarcely pyriform, had a pretty uniform thickness of 
0.002^^^ had no point, and were from 0.012^^^—0.014^^^ in length. At the pe- 
riphery of the retina, these little bodies were thicker, assumed rapidly a more 
pyriform or oval shape; so that, with a length of 0.008^^^, their greatest breadth 
was 0.003^^^ — 0.004^^^. Their somewhat conical points, which, in the peripheral 
parts, were marked off by a transverse line, had a length of about 0.006^^^ ; the 
isolated rods were about''0.0008^^^— 0.0009^^^_in breadth, and 0.012^^^—0.014^^^ 
long. It was also observed, by careful focalizing, that the points of the cones 
lay somewhat deeper than the extremities of the rods. Vertical sections through 
the yellow spot showed a remarkable thinness in this situation ; the yellow dif- 
fused colour had its seat in the middle layers ; but little, if at all, in the inner 
cell and outer rod-layers. 

Bergmann, of Rostock, had an opportunity of investigating the structures of 
the eye in the case of a beheaded criminal, six hours after death. His views 
differ somewhat from those of Kolliker. 

Half of one retina was examined fresh; the section had been made through 
the middle of the yellow spot, behind which only small cones were found, some 
with numerous rows of rods between them ; but this part of the investigation 
appears to have been very incomplete, owing to the structures breaking up into 
fragments, the localities of which could not be determined. 

The second eye was prepared and hardened before section, and consequently 
the retina exhibited no folds; but there were some differences of level, owing 
to the difference of thickness in different parts, while, probably, a great part 
resulted from the action of the chromic acid. The small angular fovea centralis 
lay very sharply defined in the middle of a somewhat pyriform field, the point 
of which was turned towards the colliculus of the optic nerve. This space was 
bounded on its upper and Under sides by delicate borders, which did not reach 
completely to the point; but there intervened between them here a middle ele- 
vation, the plica centralis of former observers. The borders inclined towards 
each other, but did not touch. Bergmann proposes to call this little field the 
Area centralis retinge. In this area the nervous layer becomes suddenly very 
thin. Some sections from the optic nerve to the fovea showed well the parti- 
cular disposition of the nervous matter in this situation ; the layer of ganglionic 
bodies was found not to be continued over the base of this depression, while 
both the granular layers, with the intergranular layer, though very thin, were 
continuous throughout. Bergmann uses this as an argument against the opinion, 
that the ganglionic bodies constitute the perceptive part of the retina. Kolli- 
ker, Hannover, and others, consider the fovea as a physiologically imperfect 
part. Bergmann describes a peculiar arrangement of the fibres in the neigh- 
tDOurhood of the fovea, by which those coming from the outer granular layer 
take an oblique course, and finally pass into the inner layer. This observer 
claims for this portion of the retina a higher physiological importance than is 
accorded to it by others. — Brit, and For. Med.-Chirurg. Rev. April, 1855, from 
Henle and Pfeuffer^s Zeitschrift, Bd. v. 

3. Composition and Action of the Gastric Juice. — Notwithstanding the nume- 
rous investigations to which the gastric juice has already been subjected, the 
observations made by Drs. 0. de Grunewald and De Schroeder on a woman 



1855.] 



Anatomy and Physiology. 



179 



affected with fistula of the stomach will be read with interest. This woman, 
aged 35, and enjoying good general health, weighed 53 kilogrammes [nearly 
117 lbs. avoirdupois], and was suckling an infant at the time she was under 
observation. The fistula, which was of two or three years' standing, had 
doubtless been produced by a perforating ulcer of the stomach. The quantity 
of gastric juice secreted was estimated, exclusively of the saliva: 65 grammes 
[a little more than two ounces] per hour, at 584 grammes in the hour, or 14.016 
kilogrammes [nearly 31 pounds] daily. This enormous proportion is much 
greater than that given by Bidder and Schmidt' — 6.4 kilogrammes [a little 
more than 14 lbs.] each day. The smallest quantity was collected in the morn- 
ing, fasting; however, it was never less than from 40 [?] to 400 grammes 
[about 13 ounces] in the hour. The fluid then obtained was in general clear, 
serous, and colourless ; at other times it was more viscid, it sometimes con- 
tained bile, without any sign of functional derangement being present. Sar- 
cinse were, with the aid of the microscope, pretty often observed. 

As to the chemical constitution of the juice, which was investig.3,ted by Dr. 
Schmidt, the fluid obtained early in the morning, while the woman was fasting, 
was either neutral or slightly alkaline ; after food was taken it was always 
acid. No hydrochloric acid was found in the analysis of several portions of 
gastric juice collected at different periods of the day ; the presence of butyric 
and lactic acids is more probable. The following is n,rdsum^ of these analyses. 
In 1,000 parts he found, water, 956.595 ; solids, 43.405 — the latter consisted of 
organic matter, 36.603 ; inorganic, 6.802 ; the inorganic contained chloride of 
sodium, 4.633 ; phosphate of lime, 0.961 : of magnesia, 0,260 ; phosphate of 
iron, 0.006 ; potash belonging to the organic substances, 0.363. 

The organic substances consisted of coagulable albuminous matter (pepsin), 
sugar, butyric acid, uncoagulable protein substances, and lactic acid. The 
organic acids are not considered as primarily present in the gastric secretion, 
even as products of the ingested aliments ; they vary in quantity according to 
the quality of the nourishment. Hydrochloric acid, on the contrary, has been 
regarded as an essential compound, although the analyses do not exhibit it, 
doubtless because it is easily neutralized by the alkalies of the saliva. 

In one analysis, Schmidt found free hydrochloric acid, but only in the pro- 
portion of two parts in 1,000, a ratio ten times less than in the dog. As to the 
question whether the gastric juice prevents the saliva converting starch into 
sugar, as Bidder and Schmidt assert, the authors found that the action of the 
saliva was not destroyed ; they, however, confirm the observation of those 
chemists that sugar is not to be found in the stomach of the dog, even after 
the ingestion of boiled starch. 

Tha digestion of protein aliments was examined by introducing into the 
stomach through the fistula a certain weight of coagulated albumen, meat, &c., 
inclosed in thin linen bags ; the loss of substance of the particles during a 
given space of time was thus observed, as well as the changes which took place 
in the microscopic structure of the elements. It was thus found that for pro- 
tein substances the solvent power of the human gastric juice is far inferior to 
that of the dog. Solution is perfected in the stomach of the dog in from two to 
four hours, while in that of man it requires nineteen or twenty hours. Raw 
meat is better digested by the human stomach than dressed meat, and veal 
than beef. 

As to the microscopic alterations, the primary fasciculi were found after an 
hour and a half easily separable from one another, without having themselves 
undergone any change, the sarcolemma was destroyed. After two hours and 
three-quarters, the primary bundles began to show transverse fissures ; after 
three hours, only striated lamellse were seen transversely ; after three hours 
and a half, besides quadrilateral lamellas, there were some primary fasciculi, 
longitudinally and transversely fissured, frequently denticulated at their ex- 
tremities ; after three hours and three-quarters, the primary fasciculi were two 
or three times longitudinally divided. After four hours and a half, there was 
scarcely any solid residue in the stomach, with the exception of a small num- 



1 Die Verdauungssaefte und der Stoffwechsel; Mitau und Leipzig, 1852, p. 36. 



180 



Progress of the Medical Sciences. 



[July 



ber of primary bundles, much fissured both longitudinally and transversely, 
but still exhibiting the transverse striae. At the end of three hours and a half, 
or four hours, the stomach was in general empty ; the protein substances were 
then submitted to the influence of the intestinal secretion. As to the digestion 
of fat, the membrane of the cells is dissolved in the stomach, but the fat itself 
does not undergo any alteration.. Milk, after three-quarters of an hour, formed 
a thick coagulum, inclosing a large quantity of milk globules and of free fat. 
At the end of two and a half hours, the casein was observed in part as an 
amorphous substance, in part as membranous and transparent fragments, with 
some unaltered milk globules ; at the end of three hours and three-quarters 
scarcely any remained in the stomach. 

These changes, which in the stomach of this woman required three hours 
and three-quarters, or four hours and a half, were completed in the stomach of 
a dog in two hours. — Dublin Quarterly Journ. of Med. Sci., May, 1855, from 
Archives G€ntrales de Med., Feb. 1855. 

® — - , 

4. Micrological Characters of Lymph. — A rare and very remarkable case of 
lesion of the lymphatics has given to M. Gubler an opportunity of analyzing 
this fluid, so seldom in the human subject recorded to have been submitted to 
chemical or microscopical examination. We, therefore, produce here the most 
important results of the observation. 

A female, in a good state of general health, presented, at the anterior and 
superior part of the left thigh, about two centimetres below the fold of the groin, 
several small phlyctenulae, or translucent vesicles, of the appearance and size 
of a grain of sago boiled. They were covered only by the epidermis, and ap- 
peared manifestly to result from a varicose dilatation of the sub-epidermic lym- 
phatics. They were disposed in two divergent lines, inclosing a very acute 
angle, the apex of which corresponded very nearly with the opening of the in- 
ternal saphena ; the sides, diverted outwards, were lost before they reached the 
inguinal region ; the superior followed exactly the fold of the groin ; the in- 
ferior ran a little more transversely. There were four very apparent and pro- 
minent vesicles a little lower down, and lying on the border of the sartorius. 
The largest amongst them, when torn with the point of a needle, gave exit im- 
mediately to an opaline fluid, which ran in a little stream down the thigh, 
falling at the rate of about fifty drops per minute, and this continued until ar- 
rested by compression. The smaller vesicles gave exit to but a very small 
quantity. This liquid, collected in a vessel, coagulated, in from one quarter to 
half an hour, in the same manner as blood — that is to say, it formed a clot 
swimming in a fluid; but the serum, so to speak, retained the same colour as 
the clot, was undistinguishable by the sight, and could only be recognized on 
shaking the mass. 

Submitted to chemical and microscopical analysis, this fluid was found to 
present the characters assigned to lymph. Other abnormal conditions of the 
lymphatics existed in this limb, which it is not necessary to specify here. It 
may be mentioned, however, that on one occasion lymph escaped from a rup- 
ture of one of the vesicles, and continued to flow for forty-eight hours ; and it 
has been calculated that about 2,830 grammes, or nearly six pounds, escaped in 
the twenty-four hours. 

Physical properties. — At the moment of exit from the vesicle, the liquid was 
white, opaque even when seen in drops, having much the appearance of milk 
deprived of its cream, with a slightly dull yellow tint. It had a strong alkaline 
reaction, a feeble saline taste, and a scarcely sensible animal odour. As before 
observed, it separated into a serum and clot, the former still retaining the opaque 
white colour, and scarcely distinguishable from the latter. 

Microscopic examination, with powers from 300 to 500 diameters, — A con- 
siderable quantity of yellowish corpuscles occupied the field, similar to those 
of blood .recently withdrawn from the circulation, but of very unequal size. 
Some had the usual dimensions of blood-corpuscles, but the greater part were 
sensibly smaller, reaching a diameter of only j^o*^ of a millimetre. Lastly, 
there existed a certain quantity of coloured corpuscles, like the preceding, but 
much smaller, being only about half the dimensions in diameter of the larger 



1855.] 



Anatomy and Physiology. 



181 



ones — that is, about o^^li of a millimetre. These little globules were seen to be 
rounded on all sides as they rolled over the field; they were constantly sphe- 
roidal, and exhibited no flattening, excavation, or anything which indicated a 
nucleus; their surface was smooth, their outlines regular, and their yellow 
colour appeared as intense as that of the best formed blood-corpuscles, if not 
even more so. 

Besides these coloured corpuscles, which, in the opinion of Gubler and Qu6- 
venne, are to be regarded as only modifications of those of the blood, there were 
others less numerous, and pale or colourless, and of very various dimensions. 
The smallest, having the same dimensions as those last described, were white 
or colourless at a certain focal distance ; but on approximating the object-glass 
a little towards them, they appeared to present a very light greenish tint. They 
were spheroidal, covered with small but very apparent granulations, which, 
however, did not render their outline irregular. The largest of these white glo- 
bules exceeded in size the largest blood-corpuscles. Their form was regularly 
spherical, their outlines smooth and uniform, and their walls finely punctuated. 
There was no visible nucleus, and no appreciable greenish tint. These larger 
white globules, reaching to j^o^'^ of ^ millimetre, were very rare, but the smaller 
white ones were present in abundance ; intermediate ones were constantly seen. 
Lastly, there were suspended in the liquid infinite multitudes of molecular gra- 
nulations, scarcely visible from their extreme tenuity, reaching to only about 
^^^th of a millimetre in size. 

The above elements may be regarded as those proper to an average specimen 
of this fluid ; but on some occasions others were observed. Thus, in one exami- 
nation there was found a considerable number of discoid blood-corpuscles, and 
bodies analogous to the white globules of the blood; in another specimen, the 
small white globules, and the small spheroidal bodies of a hsematoid nature 
above noticed, were less numerous. With these exceptions, the same elements 
were constantly to be found, and with the same characters, the relative propor- 
tions of them alone varying. 

Certain changes were produced in these little bodies when allowed to rest, all, 
however, more or less attributable to histolytic influence, and, as we conceive, 
in no way characteristic ; the discoid bodies became globular, granular, and 
mulberry like, and were at the same time diminished in diameter. The small 
spherical blood-globules manifestly multiplied as the lenticular bodies disap- 
peared ; a part of the molecular granules grouped themselves into pellicular 
masses, more or less extensive, in which were to be seen some very brilliant 
globules (oil particles). 

Weak acetic acid dissolved almost all the red globules, which first became 
enlarged ; a few of the colourless corpuscles resisted its action for some time, 
but finally disappeared. The white globules were greatly altered by this re- 
agent, but did not become dissolved; the largest became much swollen, their 
cellular wall becoming pale and thin, and losing its punctuated appearance. 
The granulations assembled in the cavity of each cell in a single rounded mass, 
resembling in form and aspect an ordinary ex-centric nucleus. In the small 
white globules, the granulations of some became more apparent on the addition 
of the acid ; others exhibited a very pale zone, which seemed to be a rudimentary 
cell-wall, closely embracing a granular nucleus. By the action of ammonia, 
also, the red globules instantly disappeared ; the white globules dissolved in 
this reagent, but more slowly. The molecular granules were dissolved by ether, 
oily drops resulting on its evaporation. Iodine coagulated the albuminoid mat- 
ter, and coloured it yellow, as well as the globules. Water swelled out the dis- 
coid bodies, and rendered them vesicular, depriving them at the same time of 
their colouring matter. 

The clot was composed of a mass, which appeared amorphous when thick, 
but which was manifestly fibrous and striated when examined in thin particles, 
and showed delicate fibrillae under the microscope. The following is a risumS 
of the observations on the microscopic elements of this lymph. 

It contained, in suspension in a serous liquid: (1) hsematoid corpuscles, al- 
ways of a diameter inferior to those of blood, some lenticular-like blood-cor- 
puscles, prope]>ly so-called, others very small, spheroidal, and smooth ; (2) pale, 



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scarcely-coloured globules, being those more usually designated as lymph-cor- 
puscles, some exceeding in size the red corpuscles of blood, others much smaller; 
(3) granular fatty molecules. 

The authors regard the first-named elements merely as modifications of the 
blood-corpuscles, presenting a similar aspect and similar chemical reactions ; 
the second resemble the white corpuscles of the blood, but difi'er from them in 
certain regards; these are the veritable corpuscles of lymph of authors. The 
difference between the white globules of the blood, and the large white glo- 
bules of lymph, seems, according to MM. Quevenne and Gubler, to be mani- 
fested chiefly in the difi'erent comportment of their nuclei to acetic acid ; but 
they do not attach much importance to it. — Brit, and For. Med.-Chirurg. Rev. 
April, 1855, from Gazette Medicate de Paris, No. xxiv. 1854. 

5. Regeneration of Nerves. — Schiff considers that the regeneration of nerv- 
ous tissue takes place by the formation of new fibres in the old sheaths, even 
before the previous ones are completely disorganized. At the seat of section, 
the parts become red, and somewhat swollen; and between the bundles of 
fibres, small, rounded, or angular nuclei, with nucleoli, show themselves ; be- 
tween them will be seen a quite structureless mass, resembling connective 
tissue, in which soon appear nuclei in rows, and at first round, but afterwards 
oblong, and placed opposite, but in alternate order. On the appearance of 
these nuclei, the mass becomes separable into laminae, in which the continua- 
tion of the primitive fibres of both ends of the nerve are visible. While at 
first the whole mass comports itself to potash and acetic acid, like areolar tissue, 
the cylinder fibres now, on the addition of potash, distinguish themselves from 
other fibrous tissues, assuming a pale yellow colour, and clear contour. These 
stages of the development proceed from both ends to the centre uniformly; but 
the following changes take place more rapidly in the upper. The substance 
lying between the rows of nuclei acquires a finely striated appearance, and on 
the side of every finely striated portion may be seen a dark line, which is the 
expression of a membrane in which the nuclei are placed. The cylinders as- 
sume by degrees a somewhat marked, pale grayish-yellow colour, so that the 
new nerve has now the appearance of the primitive fibres of the olfactory, and, 
like this, shows here and there indications of a double border, but it is not so 
dark; the outer line of this double border is stronger than the longitudinal 
striation in the substance within. Potash brings out the cylinders very clearly, 
but does not attack them. Acetic acid shows the nuclei distinctly. Somewhat 
later, the dark investments of their contents (axis-cylinders) seen in the single 
nerve fibres are, as it were, removed, and between them lie broad quadrangular, 
or somewhat rounded laminae, which are found to be fat; when these laminae 
exist, the nuclei of the sheath are no longer visible ; their number increases, 
and they at last become united to the sheath, which is at first very thin, and 
but slowly increases in thickness, and hence the newly-formed nerves for a long 
time exhibit a small diameter. This author does not agree with Kolliker in the 
opinion that the formation of a nervous cicatrix is quite parallel to that of em- 
bryonal nerve tissue. As to the period at which a regenerated nerve is capable 
of reassuming its functions, Schiff has observed that, in the infra-orbital and 
lingual nerves, the communication of sensations was re-established before the 
regeneration of the marrow in the new part was completed, and at a time when 
only single fat particles showed themselves in parts remote from each other. 
The sensitive, and probably also the motor communication, would seem to re- 
quire, not the marrow, but the axis-cylinder. The period occupied in the regene- 
ration is from eleven to seventeen days ; it is shorter in wounds by section than 
in those by laceration. The vascular nerves heal more easily and quickly than 
the sensitive, and these, again, than the motor nerves. 

The observations are very well borne out by the investigations of Bruck, on 
the sciatic nerve of a cat, which had been cut across in the middle of the thigh, 
and examined some months after, when the powers of the extremity had been 
completely restored. The regeneration appeared to be as complete as possible, 
union having taken place fibre for fibre, there being no blind or ununited ex- 
tremities; and in each fibre the cicatrix was still visible where the junction of 



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Anatomy and Pliysioloyy. 



183 



the divided parts had been effected. Nowhere was it observed that two or more 
fibres were united together, nowhere was there any intermediate substance, exu- 
dation, or callus ; each end of a central fibre had again found a peripheral fibre, 
with which it had united so as to form a continuous and isolated line. Above 
and below the cicatrix, the fibres in all these parts, and in all their relations, were 
perfectly normal. The seat of the cicatrix was marked by a more or less deep 
circular constriction of the nerve tubes, which on both sides of it were some- 
what swollen out, and flask-like. The marrow was in all the fibres, as well 
above as below the cicatrix for a short distance, somewhat granular, finely 
striated, and presented a double contour; but at the point of section, and in 
the dilated parts, it was completely clear and transparent. In this clear space, 
without the application of reagents, and without further preparation, the axis- 
cylinder could in many instances be seen, its diameter sometimes unchanged, 
or, as it might be, a little enlarged or diminished. In a few instances it stop- 
ped short on one side or the other, and was no longer visible. The regenera- 
tion was most complete in the outer sheath and the axis-cylinder, while the 
nerve marrow was sometimes not complete, or replaced by another transparent 
substance. — Schmidt's Jahrhiichei\ No. 9, 1854. 

6. Begeneration of Tendons. — Boner has instituted some experiments on the 
regeneration of tendon, for which purpose he made sections of the tendo- 
Achillis in the rabbit, and examined the parts at various times after the date of 
section. He finds that when a plastic exudation takes place, the walls of the 
sheath of the tendon become united, and finally degenerate into a thin solid 
string, the use of the tendon becoming permanently lost. On the other hand, 
when an effusion of blood takes place, perfect union of the divided parts is 
subsequently brought about. The effused blood coagulates very soon, the 
blood-corpuscles become disintegrated, the fibrin softens, and, after a couple of 
days, the whole presents a homogeneous, here and there granular, appearance. 
On the fourth day, the blood-corpuscles have almost completely disappeared, 
the whole mass being uniformly red, and filled with granules; round cells, with 
large indistinctly-bordered nuclei, begin to be seen, but soon lose their rounded 
form, and become elongated, the nuclei assuming a spindle shape. In eight to 
ten days, the coagulum has become almost completely white, the cells are very 
delicate in outline, and thin prolongations are thrown off from them, which here 
and there may be traced connecting one cell with another. The intercellular 
substance shows a clear longitudinal striation, which is more marked each day, 
and the whole coagulum more and more assumes the appearance of a true ten- 
don, the tendinous tissue being completely organized about the end of the second 
week; it is not, however, till the fourth week, or even later, that the normal 
strength and consistence of tendon are assumed. 

Boner concludes from his investigations that the structure of tendon, like that 
of the cornea, is made up of flat stellate cells, or a fibrous intercellular substance 
— Med.-Chirurg. Rev., April, 1855, from Virchow's Archiv., Bd. vii. Heft. 1. 

7. Structure of the Starch Granule. — The observations of M. Martin, of 
Vienna, which Mr. Bush believes he has confirmed, have led to t^e view that 
the starch granule is a vesicle compressed into a disc-shaped body, and having 
its edges rolled inwards upon themselves, the concentric strise on the granule 
indicating the coils of the volute thus formed. In repeating and modifying the 
experiments on which this opinion was founded. Dr. Allman was led to doubt 
the accuracy of the view adopted by these gentlemen ; and, from his observa- 
tions of the action of heat, iodine, and sulphuric acid, on potato starch, considers 
that the following conclusions may be drawn : 1. That the starch granule con- 
sists of a series of lamellae in the form of closed hollow shells, included one 
within the other, the most internal inclosing a minute cavity filled with amor- 
phous (?) amylum; that the concentric striae visible in the granule indicate the 
surface of contact of these lamellae; and that the so-called nucleus of Fritzsche 
corresponds to the central cavity. 2. That while the lamella appear to be all 
identical in chemical constitution, yet the internal differ from the external in 
consistency, or other conditions of integration. 3. That the order of deposition 



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of the lamellce is centripetal. 4. That while the starch granule is thus a lamel- 
lated vesicle, it cannot be included in the category of the true vegetable cell, 
from which it differs, not only in the absence of a proper nucleus, but in pre- 
senting no chemical diflference between membrane and contents. — Quarterly 
Journal of Microscopical Science, April, 1854. 



MATERIA MEDICA AND PHARMACY. 

8. Action of Digitalis. — Dr. H. Bence Jones, in an instructive lecture re- 
cently delivered before the Royal College of Surgeons [Medical Times and 
Gazette, April 21, 1855), gives an account of some interesting observations, by 
Dr. Traube, on the action of digitalis : — 

"E. Weber has shown,'' he observes, "that, when the vagi are undivided, a 
feeble electric current acting on the medulla oblongata, or on the vagi, causes 
a diminution of the contractions of the heart. 

"Ludwig has proved that, in all mammalia, section of the vagi in the neck is 
immediately followed by increased frequency of the heart's action. 

*' We must recognize in the heart two systems of nerves — 
" 1st. Musculo-motor, causing contraction. 
" 2d. Regulator system. 

" The ganglia of the heart are the centre of the first system, and the medulla 
oblongata is the centre of the second system. The regulating nerves pass with 
the vagi. From the experiments of Weber and Ludwig, it follows ; 1st. That 
abnormal gentle stimulus of the regulator-nerves diminishes the frequency of 
the heart's action ; and 2dly. That the frequency is greatly increased by the 
removal of the regulating action. 

"From this it may be concluded, that any substance which, when brought 
into the circulation in small quantity, diminishes the frequency of contraction, 
but, in large quantity, increases the frequency, acts on the regulator-nerves. 
Hence digitalis, from Dr. Traube's experiments : 1st. Stimulates the regulator 
system of nerves. 2d. Paralyzes the regulators : and when it stops the action 
of the heart ; then, 3dly. It paralyzes the musculo-motor system. 

"In small doses, the digitalis acts as a stimulant; in large doses, it acts as 
a sedative, causing paralysis and death." 

Dr. Traube has also made some interesting observations on the reduction of 
temperature of the body by the action of digitalis. The determination of the 
animal heat was always made in the axilla, and in twelve cases of acute rheu- 
matism, the rate of the pulse and the temperature of the body were taken with 
extreme accuracy, morning and evening ; half a drachm of the leaves of digi- 
talis were infused in four ounces of water, and every two hours half an ounce 
of the infusion was given. The result was, that generally the temperature fell 
at the same time, or shortly after the digitalis produced its effect on the heart. 
Hence, without doubt, the reduction of temperature was a consequence of the 
slower current of the lilood which was produced by the action of the digitalis on 
the regulatory system of nerves of the heart. 

Careful observation showed that digitalis caused a reduction of the tempera- 
ture in the most different kinds of febrile complaints. Even in puerperal fever 
the temperature falls when the digitalis is in action. 

Dr. Traube draws the following comparison between bloodletting and digitalis 
as antiphlogistics. Bleeding, while it lessens the force of the pulse, reduces 
the specific gravity of the blood, and in low inflammations increases the tendency 
to serous effusion. Hence, in all low inflammations, digitalis is to be preferred 
as an antiphlogistic to bleeding. Moreover, the effect of venesection is much 
more rapid, and much more transitory; in its antiphlogistic action digitalis 
bears a close resemblance to antimony ; but it is far' less likely to affect the 
bowels, and hence, in all inflammatory diseases complicated with any affection 
of the bowels, digitalis is to be preferred to antimony. The employment of 



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Materia Medica and Pharmacy. 



185 



digitalis is, however, accompanied by its own inconveniences and even dangers. 
It may produce sudden prostration of nervous and muscular action, and even 
syncope and death ; that is, the stimulating action on the regulatory system of 
nerves may suddenly give place to the paralyzing action. Hence arises the 
necessity for watching those who are taking this medicine; they should be 
seen at least twice daily, and if there be sickness, or irregularity in the rhythm 
of the heart, or great reduction in the rate of the pulse, the medicine must be 
omitted. 

9. Source of SarsapariUa. — After a careful investigation of the subject, Dr. 
Berthold Seemann has arrived at the conclusion that the greater proportion 
of sarsaparilla imported under the commercial names of "Jamaica,^' " Lisbon,'^ 
or " Brazilian, and " Guatemala,'^ or "Bed Paraguay^^ sarsaparilla, is the 
produce of one species only, the Smilax officinalis of Humboldt and Bonpland ; 
and further, that the Smilax medica of Schlechtendahl and Chamisso, and the 
Smilax papyracea of Poiret, are identical with it. Smilax officinalis grows in the 
lower coast region as well as on the mountains to an elevation of five thousand 
feet above the sea, and is confined, as far as is known, to the South American 
continent, between the 20th degree of north latitude and the 6th degree of south 
latitude, and the 110th and 40th degrees of west longitude. The roots, which 
form the commercial article, abound more or less in starch, according to the 
age and the conditions under which they have grown. Dr. Seemann considers 
the Lisbon sarsaparilla to diS'er from the Jamaica only in the rootlets having 
been removed by some mechanical means or other before the article reaches 
the market. The condition indicated by the chief pharmacological distinction 
into " mealy" and "non-mealy'^ samples, he believes to depend on the age of 
the roots, and on the locality in which they are collected. He admits, how- 
ever, the value of the commercial distinctions as such ; for as long as the Bra- 
zilian collectors continue to strip the roots of their beard and put them up in 
long bundles, there will always be Lisbon sarsaparilla; as long as the inhabit- 
ants of the Spanish Main continue to preserve the rootlets, we shall have 
Jamaica sarsaparilla ; and as long as the climate and other physical conditions 
of Guatemala remain unchanged, we shall continue to receive from that locality 
sarsaparilla distinguished by its abundance of starchy matter. — Association 
Medical Journal, March 16, 1855, from Pharmaceutical Journal, February, 1854. 

10. Pterocarpus Erinaceus or Kino-Tree of West Africa. — Dr. W. F. Daniell 
being stationed at Macarthy's Island, on the Gambia, availed himself of the 
opportunity afforded him of investigating the botanical source of African kino, 
and concludes that it is derived from a tree whose botanical characters corre- 
sponded with those of the Pterocarpus erinaceus ; a specimen of which, brought 
from central Africa, in 1805, by Mungo Park, is preserved in the British Mu- 
seum. Though growing on the banks of other streams in Western Africa, it 
flourishes most exuberantly on the upper banks of the Gambia. Macarthy^s 
Island, prior to its occupation, was thickly covered by this tree. The tree is 
described and figured. 

The gum, when it naturally exudes, is in limited quantities between the cre- 
vices of the bark, and cannot be detected on account of the external crust being 
black, and unless the outer has been purposely abraded or incised, with the 
view of obtaining a larger amount, is likewise somewhat difficult of collection. 
The exudation, as it first appears, is of a pale and dirty reddish hue ; more 
copious, and of greater liquidity, if the younger branches or twigs are cut. 
This gradually darkens in colour in proportion as it becomes exposed to the 
air ; and as exsiccation is effected, assumes a ruby tint, which time deepens 
more and more. In general, African kino oozes forth in very superficial layers, 
remarkably friable and brittle, and adheres with such tenacity to the abraded 
surface that it is almost impossible to procure any quantity without being con- 
joined with a portion of the woody fibre. Owing to its extreme brittleness, 
wheresoever the larger masses are fractured, the fragments are necessarily 
small and pulverulent, inodorous, of an irregular angular form (those from the 
interior being shining), and of a deep ruby colour ultimately acquiring a 



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Progress of the Medical Sciences. 



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brownish shade by atmospheric exposure. The most propitious time for pro- 
curing the gum is in the months of March and April, from trees of moderate 
dimensions. The means most efficient to facilitate its exudation is by a number 
of transverse incisions or abrasions in the bark, a few feet from the ground. — 
Ibid., from Pharmaceutical Journal, August, 1854. 

11. Cyanuret of Mercury. — M. Desmartis, of Bordeaux, after a careful com- 
parison of the effects produced by the different preparations of mercury, has 
come to the conclusion that the cyanuret is superior to all others, especially in 
syphilis. He believes it to be at the same time efficacious and innocuous in its 
action ; he never saw it occasion salivation or any intestinal irritation ; and 
often, when all the preparations of the metal had failed to produce benefit, he 
has seen it restore to health patients whose cases seemed hopeless in the ex- 
treme. He has found its use to be efficacious in certain cases where the 
patients had suffered, for a long period, obscure pains, for which no cause 
could be discovered. He has employed it with benefit in iritis, and in syphili- 
tic affections of the nose and fauces. — Dublin Hospital Gazette, April 1, 1855. 

12. Modes of Exhibiting Iodine. — It may be questioned whether the desire to 
avoid complexity in prescribing, which has recently become so prevalent, does 
not on some occasions materially interfere with the efficiency of our therapeu- 
tics. In the London Hospitals, the iodide of potassium is, for instance, almost 
constantly used alone, whenever the specific effects of iodine are desired. Now, 
although we have, perhaps, no single remedy whose powers are more incontes- 
tably proven than those of this salt, yet there are considerable reasons for doubt- 
ing whether its effects may not often be very much increased by combination 
with iodine itself. Most of our pharmacopeias contain formulae for compound 
solutions, and such, it is well known, were those employed by Lugol and others, 
who were the first to examine into the properties of the remedy. It was, how- 
ever, early observed, that the iodide of potassium appeared to possess all the 
specific powers of iodine, and, from its being a salt of easy use, and very man- 
ageable, it soon came to be the favourite preparation. Mr. Lloyd, of St. Bar- 
tholomew's Hospital, is one of the few surgeons who still entertain a strong 

. opinion as to the superior efficacy of the compound formulae, and the result of 
some cases which we have recently observed under his treatment have strongly 
supported his view. One of these was that of a woman, who for several months 
had been attending in the out-patients' room, and taking the iodide in large 
doses on account of a severe form of constitutional syphilis, marked by an 
ulcerating tubercular eruption and ulcerated throat. No benefit having accrued, 
she was ordered for admission, and came under the care of Mr. Lloyd. The 
remedy ordered was the following: R. Tinct. iod. co. Hbx, potas. iod. gr. v, 
aqu93 §x. Ft. haust. in ter dies sumend. ; and under it the most rapid benefit 
ensued, and a good recovery resulted. Mr. Lloyd stated, in directing the atten- 
tion of his clinical class to this case, that he was accustomed to observe very 
frequently that patients who had long taken the iodide without benefit would 
improve at once on the addition of iodine itself to the mixture. He added, that 
he made it an invariable rule never to give iodine when there was the least 
febrile disturbance present ; always, when necessary, preceding a course of that 
medicine by a few days of preparatory treatment by purgatives and salines. 

• The dilution with a large quantity of fluid was important, in order to prevent 
the medicine from irritating the stomach. If otherwise suitable, porter might 
be used as a diluent in place of water. All who are accustomed to use the 
iodide know that it is needful in most chronic diseases requiring it, to go on 
increasing the dose at very frequent intervals. A case of lupus, for instance, 
or of tubercular syphilitic eruption will improve rapidly for a short time, and 
then become stationary, to advance again on the addition of a grain or two 
more of the salt. In this way it is often necessary to go up to an enormous 
dose in order to have progressive improvement. It appears to be more espe- 
cially in such cases that the use of a compound solution is indicated; for, on 
the adding of a little iodine, the proportion of the iodide may be at once reduced. 
— Med. Times and Gaz., January 6, 1855. 



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Materia Medica and Pharmacy. 



187 



13. External Use of Conia. — Conia (or conein), as most of our readers are 
aware, is an oleaginous fluid, which is the active principle of hemlock. Mu- 
RAWJEFF, a Russian physician, has found it to be efficacious in the following 
diseases: [a). In chronic skin diseases, it allays irritation and favours the 
cure. He has used it successfully in eczema, psoriasis, acne, lichen, psora, 
prurigo, &c. He recommends it in favus, and regards it as a specific for that 
disease when affecting the scrotum. (6). In toothache, one drop allays the 
pain more rapidly and effectually than even chloroform, (c). In neuralgia and 
syphilitic pains of the bones, he alleges that it is not a mere palliative, but a 
radical cure. [d). In chronic synovitis, its use is beneficial, as also in allaying 
the pain of (e) incised and gunshot wounds, [f). In scrofulous and rheumatic 
inflammation of the eyes, it speedily diminishes the severity of the symptoms. 
[g). It palliates the pain in scrofulous and cancerous ulcers. The mode of its 
employment is as follows : In skin diseases, an ointment is used composed of 
from twelve to twenty-four drops of conein to ^i of ung. simpl. or cold cream. 
The diseased parts having been first rubbed with soft flannel, the ointment is 
applied to them, and they are then covered with oiled silk and a bandage. In 
neuralgia, he first washes the part affected with spirits of wine, and then ap- 
plies to it three or four drops of pure conein, covering it thereafter with oiled 
silk and a bandage. In cancer, he mixes the alkaloid with mucilage, and 
applies it to the diseased surface with the finger, previously covered with a 
glove. For a collyrium he adds 1-3 drops to ^vi of Aq. destil. and ^ij of de- 
coct, cydonii ; and, when used as an enema, he administers two or three drops 
in starch emulsion. — Dublin Hospital Gaz- April 15, 1855, from Med. Zeit. 
Russl. 17, 1854. 

14. External Uses of the Acid Nitrate of Mercury. — A solution of the nitrate 
of mercury in strong nitric acid is in very common use at the Hospital for Cuta- 
neous Diseases, and constitutes a very convenient form of caustic. Its formula 
is — R. Hydrargyri Jj, acidi nitrici (specific gravity 1.50) ^ij ; solve. The 
solution produced is a clear, colourless fluid. The following may be mentioned 
as some of its chief uses : — 

In Carbuncle. — Mr. Startin usually applies the caustic if the carbuncle be of 
not more than moderate size, to but one central spot, where it is freely painted 
for an extent of about a shilling in size. Its effect is to produce an eschar, from 
beneath which the core afterwards escapes. 

In Acne. — A very minute drop of the acid is placed, by means of a finely- 
pointed glass brush, on the apex of any indolent tubercles, whether suppurated 
or otherwise. It has the effect of opening the pustule, if matter have formed, 
and if not, induces the disappearance of the induration. The application is 
followed only by a little smarting pain, and if it have been carefully made leaves 
no scar. 

In Boils. — There can, we think, be little doubt as to the superiority of the 
caustic treatment over that by the knife, even in the case of very large boils. 
The pain of the incision, the large sore caused, and the unsightly scar which 
follows, constitute very formidable drawbacks to a practice for which there is 
no real necessity. At this hospital, where cases of boils are very common, the 
knife is never resorted to. The general treatment consists in giving aperients 
and steel conjointly, and the local in applying to the apex of the furuncle a 
full-sized drop of the acid nitrate solution. The morbid action generally ter- 
minates coincidently with the application, and the core is thrown off through a 
comparatively small opening, the resulting cicatrix being insignificant. 

In Lupui. — The acid nitrate is one of the most efficient and convenient forms 
of caustic in this disease. Mr. Startin does not, however, employ it solely, but 
uses also the biniodide of mercury, and a paste of which arsenic is the principal 
ingredient. The acid nitrate is chiefly used in indolent tubercles, and to indu- 
rated patches not actually ulcerated. After ulceration has occurred the arseni- 
cal paste is preferred. 

For Sloughing Ulcers. — The practice of treating unhealthy ulcerations, 
wherever situated, by means of caustics, is much pursued at this hospital, and 
with excellent results. The pain attending the application of nitric acid has 



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[July 



been much overrated by the profession generally, and its use has consequently 
been avoided in many instances in which it would have been efficient to com- 
pletely change the course of the morbid action and induce healthy processes. 
Its powers in cases of phagedsena are now widely recognized, and its use will 
probably soon extend to various other kinds of ulceration of somewhat similar 
nature, but much less severity. The pain spontaneously caused by an un- 
healthy sore during a single night is probably much more than that produced 
by an application of caustic. In most cases of sloughing or unhealthy ulcers 
Mr. Startin employs either the solution of the acid nitrate or the arsenical paste 
just referred to. The rapidity with which the surface granulates afterwards is 
often surprising. 

Ill Moles, Kcevi, etc. — Small moles on the face, if superficial and not too thick, 
may be readily destroyed by the acid nitrate. A cicatrix of course results, but 
it is small, and far less unsightly than the original disease. Small cutaneous 
nsevi are often treated both at this and the various other London Hospitals, by 
means of the nitric acid. Unless the disease be of very small extent, the em- 
ployment of a ligature appears to be a much more certain means of effecting 
the end desired. If there be a subcutaneous base to the morbid structure it 
often persists in growing, despite frequent applications of escharotics. There 
is a mild form of dilated cutaneous capillaries which produces the marks known 
as "port-wine stains,^' "spiders," etc., in the treatment of which much benefit 
may be obtained by the dexterous application of fluid caustics. "With a finely- 
pointed glass brush, charged either with nitric acid or the acid nitrate of mer- 
cury, the tortuous vascular trunks should be severally painted, a minute streak 
of the caustic being thus left along the whole course. In this way, by repeated 
applications, the whole of the larger vessels may be destroyed, and the dis- 
figurement, to a large extent, diminished. The "port- wine stain" is of course 
very much more difficult to remove than the less diff'used forms of this condi- 
tion, such, for instance, as are of frequent occurrence on the cheeks or nose ; 
even in it, however, much benefit may by patient treatment be gained.— Jfe^i. 
Times and Gaz., January 6, 1855. 

15. Glass Brushes for Applying Fluid Caustics. — It is desirable, in the use of 
any of the mineral acids as escharotics, that their strength should not be dimi- 
nished by the employment of any material susceptible of being charred. A 
serious o])jection, therefore, lies against the use of wood, cotton-wool, lint, etc., 
all of which have been recommended for that purpose. Glass is by far the 
best material, being at once durable, cleanly, easy of use, and quite insuscep- 
tible of the action of the fluid. A glass rod, rounded at one end, and drawn to 
a fine point at the other, may be made to serve most purposes, one or the other 
extremity being employed according as it is wished to apply the acid over a 
large or a small extent of surface. A few brushes, of different sizes, made of 
spun glass, are, however, yet more convenient. Those sold in the shops are 
much too large for most of the purposes mentioned in the above notice of the 
uses of the acid nitrate, and we have seen none which would exactly meet the 
required conditions, excepting those in use at the Hospital for Skin Diseases. 
With a little glass tubing, of the thickness of a quill, a skein of spun glass, and 
a little sealing-wax, they may be inexpensively made by any one of ordinary 
ingenuity. The brush part is first made by uniting together with sealing-wax 
a tuft of the spun material, and is then introduced into the end of a tube, which 
has been either flattened out or brought nearly to a point while heated. A little 
additional heat easily fixes the tuft in position, and by scissors it may then be 
cut down to the requisite size. — Med. Times and Gaz., January 6, 1855. 

16. Pencils of Diluted Lunar Caustic. — At the Samaritan Hospital, Mr. 
Spexcer Wells has introduced the use of nitrate of silver in the solid form, 
diluted by a mixture of one, two, or three parts of nitrate of potass. The salts 
are melted together, poured into moulds, and allowed to cool. Those used by 
Mr. Wells are prepared by Mr. Bastick, Chemist, of Brook Street. They have 
certain advantages in practical application over solutions of the same strength. 
"When applied to the conjunctiva of the eyelid, for instance, it is not easy to 



1855.] 



Medical Patliology and Therapeutics. 



189 



prevent a solution from extending much further than necessary, or even from 
affecting the conjunctiva of the bulb or cornea.^ On the other hand, an undi- 
luted stick of nitrate of silver acts too powerfully on the mucous membrane. 
By using the stick diluted with varying proportions of nitrate of potass, the 
required activity can be obtained, and the effect limited to the exact seat of 
morbid action. When the conjunctiva of the lid is alone affected, and it is 
desirable to avoid the action of caustic on the conjunctiva of the bulb, Mr. Wells 
is accustomed to wash the lid, after applying the caustic and before the eye is 
closed, first with a solution of common salt, which converts the unchanged 
nitrate into a chloride of silver, and then with pure water. In this manner, all 
the good effects of caustic may be obtained without any of its inconveniences 
or evil consequences, and may be limited to any desired spot. In gonorrhosal 
affections of the urethra and vagina, and in various indolent or irritable sores, 
the same mode of applying the caustic becomes useful. The saving of expense 
is also worthy of some attention in Charitable Institutions and Union practice. 
— Med. Times and Gaz., January 6, 1856. 

17. Use of Lime-Water in making Bread. — To neutralize the deterioration 
which the gluten of ffour undergoes by keeping, bakers add sulphate of copper 
or alum with the damaged flour. Professor Liebig, however, has conceived the 
idea of employing lime, in the state of solution, saturated without heat. After 
having kneaded the flour with water and lime, he adds the yeast, and leaves the 
dough to itself ; the fermentation commences, and is developed as usual ; and if 
we add the remainder of the flour to the fermented dough at the proper time, we 
obtain, after baking, an excellent, elastic, spongy bread, free from acid, of an 
agreeable taste, and which is preferred to all other bread after it has been eaten 
for some time. The proportions of flour and lime-water to be employed are in 
the ratio of 19 to 5. As the quantity of liquid is not sufficient for converting 
the flour into dough, it is completed with ordinary water. The quantity of 
lime contained in the bread is small — 160 ounces of lime require more than 300 
quarts of water for solution ; the lime contained in the bread is scarcely as much 
as that contained in the seeds of leguminous plants. Professor Liebig remarks, 
that " it may be regarded as a physiological truth, established by experiment, 
that corn flour is not a perfectly alimentary substance ; administered alone, in 
the state of bread, it does not suffice for sustaining life. From all that we 
know, this insufficiency is owing to the want of lime, so necessary for the for- 
mation of the osseous system. The phosphoric acid likewise required is suffi- 
cientl3^ represented in the corn, but lime is less abundant in it than in legumi- 
nous plants. This circumstance gives, perhaps, the key to many of the diseases 
which are observed among prisoners, as well as among children whose diet con- 
sists essentially of bread. The yield of bread from flour kneaded with lime-water 
is more considerable. In my household, nineteen pounds of flour, treated with- 
out lime-water, rarely give more than twenty-four and a half pounds of bread; 
kneaded with five quarts of lime-water, the same quantity of flour produces 
from twenty-six pounds six ounces to twenty-six pounds ten ounces of well- 
baked bread. Now as, according to Ileeren, nineteen pounds of flour furnish 
only twenty-four pounds and one-half ounces of bread, it may be admitted that 
the lime-water bread has undergone a real augmentation." — Dublin Medical 
Press, April 25, 1855, from Chemist. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

18. Hcemopfysis as a Sign of Tubercle; Curability of Consum,ption ; Effect of 
Cod-liver Oil, &c. — The value of hgemoptysis, as an indication of incurable 
tubercle and consumption, has been a medical question often debated, and this 



^ [The operator who cannot prevent this has little claim to dexterity. — Ed. Am. J.] 
No. LIX.— July 1855. 13 



190 



Progress of tlie ^ledicdl Sciences. 



[July 



sign or symptom by itself perhaps a little overrated. The chances of pulmo- 
nary hemorrhage are, no doubt, increased by whatever tends to diminish the 
capacity of the chest, as in persons of different trades — tailors, dressmakers, 
&c. — with crooked spines. Again, in advanced consumption, with cavities, one 
is too often called upon to witness total destruction of lung tissue and haemop- 
tysis. In both these, however, we may understand the cause of haemoptysis. 
In the present instance, however, we wish to speak of the popular and pro- 
fessional notion of phthisis following haemoptysis as certain, so to speak, as a 
shadow its substance, and in such matters of every-day practice as signing a cer- 
tificate for life insurance, haemoptysis is considered conclusive evidence against 
doing so. In a large number of cases where haemoptysis occurs through life, the 
tendency is evidently towards tuberculosis ; a certain proportion of cases pro- 
bably go on to consumption, whilst the residue are cured. If, out of 500 cases, 
100 or 200 escape, it becomes an interesting question, what are the general 
conditions that lead to a cure ? w^hat, on the other hand, are the conditions to 
facilitate the inroads of consumption? It is instructive to compare the results 
at a general hospital, like the London Hospital or Guys, and the results at 
Brompton. At the latter we find, on inquiry, that haemoptysis takes a very 
formidable position indeed in the chapter of symptoms preceding tubercle; we 
find also that cod-liver oil, given in over-doses or in particular cases, has a very 
manifest tendency to produce hemoptysis. Amenorrhoea, also, and heart dis- 
ease are often attended by this symptom. Leaving all these, however, out of 
the calculation, we have had reason to be more hopeful of the curability of con- 
sumption. 

We have been singularly struck with the importance of this question, and 
with the practical value of the facts springing out of it, from observing the 
notes of cases, tables, and general results arrived at from the investigations of 
Dr. Andrew Clark, at the London Hospital. It appears that Dr. Clark enter- 
tains the opinion that phthisis of a limited kind is of much more frequent occur- 
rence, and becomes much more frequently cured, than is ordinarily admitted or 
supposed. This opinion he conceives to be capable of demonstrative proof in three 
ways : first, by the results of a large number oi post-mortem examinations con- 
ducted by himself, which show that in the bodies of patients dying from accident, 
or some non-tubercular disease, obsolescent or healed tubercles are found in a 
very large percentage of cases ; secondly, by showing that out of a given num- 
ber of persons presenting themselves indiscriminately for relief at the London 
Hospital, many are found to have had haemoptysis, and that of these a certain 
proportion has proceeded to the development of unequivocal phthisis, whilst 
another proportion has appeared to terminate in complete recovery from symp- 
toms of pulmonary disease ; thirdly, by showing that cases of limited chronic 
phthisis, proved by the presence of air vesicles and tubercular matter together 
in the sputum, as we have seen it, do not unfrequently proceed to arrestment 
of the general symptoms, suspension of the progress of the local pulmonary 
lesion, and subsequent cure. 

There can be no doubt that a series of investigations in this threefold aspect, 
if followed to their utmost ramifications, and conducted with minuteness and 
care, will lead to great practical good. In the meantime, without committing 
ourselves to any specific opinion upon all the questions mooted, we are desirous 
of commenting upon the second aspect of Dr. Clark^s investigations as one 
which is eminently practical both in its relations to the disease itself in hos- 
pital wards, and to the value of haemoptysis in its bearings upon the signatures 
to life assurance, as we have already hinted. 

In the second aspect of these investigations, Dr. Clark proceeds upon the 
opinion, that in all cases when hsemoptysis has occurred to the extent of an 
ounce in the absence of amenorrhoea, aneurism, heart disease, and ulcerated 
throat, tubercular matter is really present in the lungs. He holds the same 
opinion even when the haemoptysis is to a much less amount, provided it be of 
frequent occurrence, uncomplicated with marked cough and any acute affection 
of the lung. 

Dr. Clark then proceeds to show that, out of a given number of persons 
applying indiscriminately for relief at the London Hospital, and carefully exa- 



1855.] 



Iledical Pathology and Therapeutics. 



191 



mined relative to this point, haemoptysis will be found to have occurred in a 
large percentage ; and that in these instances the heemoptysis is followed in a 
certain number of cases by the induction of phthisis and in a certain pro- 
portion by suspension of the symptoms accompanying it and ultimate reco- 
very, and immunity from pulmonary disease. Having established the fact 
that hsemoptysis, preceded, accompanied, and followed by pulmonary symp- 
toms, often disappears without the return of it or of any signs of pulmonary 
lesion for years afterwards and sometimes not at all. Dr. Clark then endea- 
vours, as the object of greatest importance in the inquiry, to determine under 
what conditions this return to health takes place ; to what extent, if at all, they 
can be superinduced by art ; and with what amount of certainty we can pre- 
dict in a given case, termination in recovery, or in phthisis. 

We have not space to enter more fully into these details at present. We have 
pointed out the broad relations of the subject, and shall satisfy ourselves with 
abstracts of a case or two as types of those in which hasmoptysis has not been 
followed by confirmed phthisis. 

J, B , aged sixty-five, a labourer, short, spare, and bent, presented for 

dyspepsia, accompanied with depression and headache. He was delicate in 
youth, and considered to be declinish" at the age of three or four and twenty. 
At that time he had cough and expectoration, and frequently spat blood. He 
used to have pain in the left side, but particularly under the left scapula and 
about the shoulder. Never had dyspnoea, and never was confined to bed for 
any length of time. Was very temperate at that time ; ate little, and took care 
of himself. Continued much in the same way for two or three years ; was 
always much subject to colds, and frequently blistered for them. Afterwards 
began to be better, exposed himself to all weathers, lost his liability to colds, 
lived rather irregularly, worked hard, took beer and spirits as occasion offered, 
and lost all note of his symptoms at about thirty, except one, which was pain 
or gnawing under the left scapula. When he has a cold now, he suffers from 
a pain in the chest, and has yellow expectoration. Does not often have a cold, 
and for some years has only suffered from occasional bilious fits and rheuma- 
tism. 

He has, at present, no distinct cough, and no dyspnoea ; has a habit, bow- 
ever, of clearing his throat, and expectorates occasionally in the morning, 
vitreous-looking gelatinous masses, about the size of peas. The pain under 
the scapula has always recurred at intervals of from three to six months, and 
lasted variable periods. Left side of chest is flatter than right, and is found, 
by placing the hands under the axilla, not to fill so well. There is dulness on 
the left side, jerking respiration, and increased vocal resonance; no rales; 
around the dulness the lung sounds preternaturally clear, as also does the 
whole anterior surface of the right lung; heart-sounds healthy; every part of 
the chest thrills with the reverberation of the patient's voice. 

We have room for the notes of only one other case, which is a sigmficant 
and instructive one, but not occurring at the London Hospital. 

Mr. B , aged nineteen, tall, slim, with fair hair, blue eyes^ large pupil, 

transparent skin, and long incurved nails, was seen, in 1846, when he pre- 
sented all the symptoms of early phthisis. After a time he got better, and was 
lost sight of for some months. In 1847, he was seen again, and had had hse- 
moptysis, followed by cough, expectoration, night-sweats, and wasting. No 
cavity could be made out, but the expectoration contained patches of air vesicles, 
which Dr. Clark has preserved. He again got a little better, and was moving 
about when he met with an accident — a fall — which was followed by the for- 
mation of an abscess on the upper and outer part of the thigh. The abscess 
was opened, discharged, and continued to discharge a large quantity of matter. 
. Under this exhausting discharge he was with difficulty supported. He became 
extremely emaciated, and almost helpless. At the same time, a remarkable 
change was observed in the pulmonary symptoms. They began to abate from 
the day the abscess was opened, and ultimately disappeared entirely. Gradu- 
ally he regained flesh and strength, and the pulmonary symptoms did not 
return. In 1848, he appeared to have perfectly recovered; but contraction 



192 



Progress of the Medical Sciences. 



[July 



having followed the obliteration of the abscess, he had left his former service, 
and become a railway clerk. 

On the 9th of November last, Dr. Clark met this patient accidentally at the 
Crystal Palace ; and so great, then, was the alteration In his appearance, that 
Dr. Clark failed at first to recognize him. He was unusually fat for so young 
a man— corpulent, in fact, and robust-looking. He declared himself to be in 
perfect health, and to have been so for some years. The pupils were still large, 
and the nails pink, long, and incurved. 

Andral states, that only in one instance in which haemoptysis had occurred 
to him — and even then the immediate cause of death — had he ever found the 
substance of the lungs free from tubercles. Louis, we need hardly say, gives 
an equally fatal tendency in 2,000 cases in which he made the inquiry, in later 
years, after the mode by Dr. Andrew Clark ; but in 87 private cases under ijis 
care, 4 in 6 had haemoptysis. 

Pinel gives a singular case of hsemoptysis in a female, which occurred regu- 
larly every month, at the woman's monthly period, during forty-two years. It 
was originally caused by fright, and was always subsequently somewhat in- 
creased by strong mental excitement. When suspended for a month or two, 
the patient invariably suffered from intense headaches. She had usually before 
the haemoptysis a sensation of weight and uneasiness about the lumbar region 
and pelvis ; soon followed by chilliness, lassitude, oppression at the chest, head- 
ache, and ultimately a distinct sensation of stinging or bubbling in the bronchial 
tubes and trachea; then, finally, sharp cough, and spitting of blood. The wo- 
man was fifty-eight years of age when it stopped ; she was stout and plump, 
what conditions here saved her from getting phthisis, like the patients of An- 
dral or Louis, would be an interesting subject of speculation. 

The older observers differ very materially as to the frequency of hemorrhage 
from the lungs in relation to tubercles. Haemoptysis may precede tubercle for 
years and years, and even be almost forgotten, till the patient is reminded of 
it. The use of cod-liver oil, we believe, has very materially changed the rate 
of mortality and curability of phthisis of late years. Andral found in those 
dying of phthisis, in his time, that one in six had never had haemoptysis at all ; 
in two in six the hemoptysis appeared to mark the development of tubercle as 
a cause ; in the remaining number, or half the deaths in Paris from phthisis, it 
followed rather as a consequence from unequivocal phthisical disease, with 
diarrhoea and wasting, and a breaking up of the lungs into anfractuous sinuses 
and cavities. — Lancet, March 24, 1855. 

19. Goitre in an Infant. — Professor Simpson exhibited, at a meeting of the 
Medico-Chirurgical Society of Edinburgh (Feb. 7, 1855), a pathological specimen 
of great rarity and of much interest, as it satisfactorily disposed of not a few of 
the current theories as to the production of the disease. Mr. Syme, for ex- 
ample, was inclined to ascribe it to the fact that persons affected with the dis- 
ease were compelled from their occupations to climb great heights, where the 
air was less dense, and who lived in valleys where there was an equal stagna- 
tion ; others ascribe it to the use of snow-water, or of water impregnated with 
iodine. Now the specimen in question proved that goitre was not due to any 
of these influences. It had been obtained from a child which lived but a few hours 
after birth. When born, it was nearly asphyxiated, and it had only been kept 
alive by the presence of a catheter in the throat obviating the pressure of the 
mass. The brain was of small size, and was covered by a quantity of watery 
fluid, on the removal of which the brain was found to occupy only the posterior 
segment of the cranial cavity. The mother was an Italian by birth, and had 
never suffered from the disease. She had had seven dead children and three 
living. The cause of this mortality was diseased placenta; and latterly she had 
taken large quantities of chloride of potass with good results. No other mal- 
formation was ever observed in her other children. In the present instance, 
labour was brought on at the eighth month by the passage of a probe between 
the membranes, as the child's heart was observed to beat slowly. The enlarge- 
ment of the neck had the same influence in throwing the head back as the arm 
of the child when placed under the chin ; the labour in consequence was tedious. 



1855.] 



Medical Pathology and Therapeutics. 



193 



Dr. Keiller had met with a similar case nine months ago, and the child, he 
\ras happy to state, was still alive. The mother came from the neighbourhood 
of Cockermouth, where he (Dr. Keiller) believed goitre was prevalent; she had 
at one time of her life been affected with the disease. The tumour in the child's 
neck had become smaller since birth. 

Dr. Simpson believed that there were different kinds of swellings met with 
in the necks of children. Large ranulee were occasionally present from an 
enlargement of the salivary glands ; a beautifal specimen of which existed in 
the late Dr. Hamilton's collection ; the tumour was fully half the size of the 
child's head. He had himself seen two other cases which occurred in the old 
town of Edinburgh, both of which proved speedily fatal from the gradual en- 
largement of the ranul^e. — 21onilily Journ. Med. Sci., April, 1855. 

20. Peculiar Concretions in Typhus Stools. — Zimmerman has repeatedly ob- 
served in the stools of typhus patients considerable numbers of peculiar con- 
cretions, which varied in size from that of a large Turkish to that of a common 
white bean. He considers that there exists some relation between them and 
the millet-seed-like white corpuscles which, it is known, are found in typhus 
stools. The concretions varied in form and appearance; some were round, 
others spherical ; some were smooth, and others rough on the surface. They 
were of a yellowish-white colour, of tolerably firm consistence, but capable of 
being crumbled between the fingers. When chemico-microscopically examined, 
they were found to contain, besides large numbers of epithelial cells, various 
fatty matters (1,000 parts contained 237.8 of solid residue, and 156.9 of fats), 
among which there was almost no cholesterine ; they also contained biliary 
constituents — a sort of albuminous substance, which Zimmerman believes to be 
casein and fibrin ; and finally various salts (viz : sulphates, carbonates, and 
phosphates of soda ; chloride of sodium, and earthy phosphates). The concre- 
tions differ from the corpuscles in their containing protein compounds, while 
the others consist of fat, with merely a little earthy matter. In the concretions, 
the mineral ingredients are to the organic in the proportion of 1 to 17 ; in the 
feces they are as 1 to 1 ; the former contain little chloride of sodium, while in 
the latter, this salt exists in large proportions — constituting nearly a third of 
the whole. 

Sigmund found similar fatty concretions in the feces of a lady affected with 
biliary derangement [Med. Chemie) ; and Kletzinsky {Heller's Arcliiv., I., 
1853) found similar fatty matter in the caecum of a person who had died of 
typhus, which was deficient in cholesterine, but contained biliary matters, in- 
testinal mucus, and various salts, especially earthy phosphates. — Monthly 
Journ. of Med. Sci., March, 1855, from Deutsche Klinik., 28, 1853. 

21. Perforation of the Septum Cordis. — Prof. Hauska, having had a heart 
sent him, as furnishing an example of the aorta arising in both ventricles, 
found, on examination, that the appearance of this being the case arose from 
the septum of the ventricles having become perforated. He takes the oppor- 
tunity to di-aw attention to an anatomical fact, allusion to which he can no- 
where find, viz : that there is in the normal state a spot in the septum cordis, 
varying in size from a bean to an almond, entirely destitute of muscular sub- 
stance ; the two chambers being there separated only by the layers of endocar- 
dium that line them. Examining the septum from the left, after slitting up the 
aorta, we may remark a thin diaphanous spot, close under the angle formed by 
the convex borders of the right and posterior semilunar valves of the aorta, 
being closed above by a thin muscular bundle, coursing along the contour of 
the ostium arteriosum sinistrum. In the right ventricle the deprivation of 
muscular substance is covered by the end of the tricuspid valve ; and so thin is 
the duplicature of the endocardium, that the lines and markings of the finger 
held under it can be seen through. M. Hauska observed the appearance him- 
self only a year since ; but since then he has found it in every heart (about 
300) he has examined, of whatever age or sex. 

This appearance is of great interest in a pathological point of view. In en- 
docarditis, the endocardium becomes loosened and friable, and it is not seldom 



194 



Progress of the Medical Sciences. 



[July 



actually torn, as the rupture of the valves and the rapid formation of aneurism 
of the heart show. If such inflammation happened to attack this spot, a comr 
munication between the ventricles, by rupture of the endocardium, might easily 
result. On examining the heart sent him as an example of anomalous origin 
of the aorta, the ostium arteriosum sinistrum was found directed towards the 
right, as well as the left ventricle, while the swollen edge of the septum ventri- 
culorum, covered with opaque and thickened endocardium, sloping from before 
backwards, was carried up to the middle of the orifice of the aorta. This con- 
dition necessarily arises as soon as the endocardium closing the aperture is 
torn. The blood of the right ventricle passes, in gradually increasing quan- 
tity, through the new opening, which becomes proportionally enlarged, and, 
owing to the simultaneous contraction of the two ventricles, the blood does not 
pass into the left ventricle, but immediately into the aorta, where it becomes 
mingled with the blood of the left side. This newly-established stream of blood 
from the right ventricle to the aorta, gradually forces the commencing portion 
of the aorta towards the right, so that at last the ostium arteriosum sinistrum 
is placed obliquely over the perforated septum, and with its orifice turned to- 
wards both ventricles. — Med. Times and Gaz., April 28, 1855. 

22. On the supposed Effects qfiJie Suspension of accustomed Stirnulanis in the pro- 
duction of Delirium Tremens. By Dr. Peddie. — In order to obtain some addi- 
tional evidence on this disputed point, I submitted some queries to Drs. Simson 
and Gibson, the medical officers of the large prison establishment of this city 
and of Glasgow, and to Mr. Page and Dr, Scott, surgeons to the county jails 
of Carlisle and Dumfries ; and the following information has been kindly fur- 
nished by them, as to the efiect of the sudden withdrawal of all stimulants from 
civil and criminal prisoners known or presumed to be of intemperate habits, 
and the immediate substitution of prison fare, which is well known not to be of 
the most generous description. 

As regards the prison of Carlisle, it appears that, although the annual num- 
ber of commitments during the last fifteen years has been about 600 ; and that, 
although three-fourths of these are considered to have been, in one way or an- 
other, the consequence of drunkenness, Mr. Page states emphatically he has 
never yet seen any ill "result from the sudden abstraction of stimulants from 
habitual drunkards, who had been drinking to excess up to the time of being 
placed on prison fare.^' Mr. Page had also, during nine years^ experience in 
connection with the Carlisle County Pauper Lunatic Asylum, observed the same 
impunity with which all stimulants could be at once withdrawn. [Letters 9th 
and 21st June, 1854.) 

Of the jail of Dumfries, it is stated by Dr. Scott [Letters 12th and 2lst June, 
1854) that, during the last fifteen years, the number of civil and criminal prison- 
ers have amounted to 5,539; that of this number he supposes about two-thirds 
were committed for crimes resulting from intemperate habits ; that he believes 
a very large number to have been habitual drunkards ; and that, although all of 
these, of course, were deprived of their usual libations, and at once put on prison 
allowance, only five eases of delirium tremens are found on the register of dis- 
ease, and that all of these patients but one were admitted to the prison with 
the disease on them ; and that in regard to that one, although entered as under 
delirium tremens on the day after admission, there is every probability for 
believing that she had had the disease on her when admitted, although not re- 
ported to be ill. Dr. Scott also notices, as an important fact, that during the 
time the railways were being constructed in the county of Dumfries, a very large 
number of navvies were committed to prison, who had led a very dissipated life 
for many months, and although deprived of liquor from the moment of appre- 
hension, not a single case of delirium tremens occurred. 

Then, as regards the prison of Glasgow, in which the annual commitments 
amount to upwards of 4,000, the experience of the year 1850 is adduced by Dr. 
Gibson [Letter of 16th June, 1854), as affording an approximation to the facts 
wished to be elicited. A calculation made in that year showed that, while 4,122 
were imprisoned, the number of assaults, with few exceptions, committed under 
the influence of liquor, and "the drunk and disorderly,^' amounted to 1,519; and 



1855.] 



Medical Pathology and Therajpeutics. 



195 



of this number only three cases of delirium tremens occurred — a very small pro- 
portion indeed, especially when it is considered tha,tthe debtors, who are almost 
all habitual drunkards, and drinking up to the moment of incarceration, are not 
included in this list. Many hundreds more, therefore, may be considered to 
have belonged to the drunken population of the jail. The average of the last 
ten years, however, is greater (5.7), there having been fifty-seven cases alto- 
gether during that period, but, after all, this is a very small proportion to the 
number of dissipated and drunken characters gathered together there, and at 
once broken off from intemperate habits. Dr. Gibson, however, states that he 
does not altogether enter into my views as to the proximate cause of delirium 
tremens, although he admits that "it does not so frequently occur as the advo- 
cates of the theory which attributes it to the total withdrawal of accustomed 
stimuli, such as Blake and others, are inclined to suppose and he mentions, 
in proof of his objection, that he had never seen it occur in less than twenty- 
four or beyond seventy-two hours after apprehension, which necessarily put a 
stop to dram-drinking. As I have already explained, however, and as the cases 
given at the conclusion of this paper will show, there is always, whether the 
individual is drinking much or little, more or less of a premonitory stage pre- 
sent in tills affection, distinguished by digestive derangement, nervous irrita- 
bility, restlessness, and sleeplessness, before much tremor is displayed, or any 
illusions manifested ; and it is easy to suppose that these might not be brought 
immediately under the notice of the medical officer of a large criminal establish- 
ment, such as the Glasgow prison. But even granting that no incipient symp- 
toms of the disease were observed, and that this proportion of the habitual 
drunkards were not quite on the verge of being affected with it, it is quite in 
accordance with the views already advanced to suppose that, when there was 
a certain amount of alcoholization existing, the disease might be hurried on 
more speedily than otherwise would have been the case in individuals of a nerv- 
ous and excitable temperament, by the agitation or shock of apprehension, 
and the deprivation of liberty. But, further, I should suppose it a very just, 
nay moderate calculation, to assume that out of a population of 2,000 confirmed 
drunkards belonging to any class of society, although enjoying unrestrained 
liberty and uninterrupted opportunities for indulgence to excess, at least from 
three to six instances of delirium tremens would annually occur. 

But, in fine, on this point, the evidence communicated by Dr. Simson, the 
medical officer to the prison board of this city [Letter 4th July, 1854), is suffi- 
ciently satisfactory ; for while the number of civil and criminal prisoners, com- 
mitted during the last year, was 5,864 (which may be assumed as a sample of 
the previous fourteen years, over which Dr. Simson's experience extends), only 
four cases of delirium tremens occurred within the last eighteen months. The 
average number of cases during former years, Dr. S. states as from 2 to 3 per 
annum. Dr. S. considers that at least one-half of the whole prisoners may be 
assumed as dissipated characters, and that at the very lowest computation, 5,00 
must have been regular systematic drunkards, from whom all drink was sud- 
denly abstracted ; and he goes on to state as his decided opinion, that "the sud- 
den taking away of spirits, etc., does not produce delirium tremens. In every 
case, the prisoner had symptoms of the disease on him when admitted — that is, 
they were all restless, irritable, etc. ; and I have no doubt, but that in many in- 
stances the crimes committed were the effects of this disease. I do not remem- 
ber a single case of delirium tremens occurring when the prisoner was quite well 
when received into prison. There is not the least doubt that a peculiarity of 
constitution predisposes to delirium tremens,^' etc. 

Here, then, it has been shown, that hundreds of individuals among the public 
at large, and of the criminals committed to our gaols, leave off or are suddenly 
deprived of the stimulants to which they had been previously addicted, without 
being seized with delirium tremens, or anything approaching to it. On the 
other hand, also, it is unquestionable that numerous instances of the disease do 
occur in which there has been no suspension either voluntarily or by compul- 
sion of the amount of liquor consumed, nay, even an increased excess in drink- 
ing up to the very moment of seizure. The assumption, consequently, that 
this disease is produced invariably, or chiefly, or even occasionally, by the 



193 Progress of the Medical Sciences. [July 

diminution or abstraction of an accustomed stimulus, is not supported by facts. 
Any cases, therefore, noticed as occurring under these circumstances, are simply 
of an exceptional character, but "which, in my apprehension, fall quite short of 
proof from the considerations already so fully explained. — On Delirium Tremens. 

23. Protracted Constipation. — Mr. Anderson related to the Harveian Society 
(Feb. 15th, 1855) a case of this in a child, aged three years and a half, who 
came under his care on the 21st of June, 1854, and had passed no motion 
since the 21st of April, although he had taken strong medicine for the purpose 
of opening the bowels. His abdomen was enormously distended, tympanitic 
from flatus, but evidently containing no fluid, and respiration was materially 
interfered with from the mechanical pressure upon the diaphragm. There was 
occasional sickness from disordered digestion, but no stercoraceous or even 
constant vomiting to indicate intussusception or any other cause of strangula- 
tion. The mother stated that the child had suffered from constipation for the 
last two years and a half, sometimes having no evacuation for a fortnight, and 
sometimes for nearly a month, but had never gone so long as upon the present 
occasion. Purgatives and enemata were used without relief until the 26th, 
when an examination was made per anum, and a hard globular mass was felt, 
distending the whole of the rectum, and precluding the possibility of defeca- 
tion. The sphincter was then dilated gradually, the mass broken down, and 
removed by means of a spoon and the forefinger ; pressure and friction were 
then applied to the abdomen, when the pent-up bowels began to act imme- 
diately, evacuating an enormous quantity of dark-coloured, offensive feces. 
Aperient medicines now acted, and under their use the bowels were thoroughly 
emptied, having been completely shut up for more than nine weeks. Tonics 
in combination with aperients were subsequently employed, and he eventually 
recovered the natural action of the bowels. This case, yielding so readily to 
treatment after the removal of the mechanical cause, led to the consideration 
of several most important points connected with such subjects. A case of Dr. 
Kidge's was quoted, in which the most undeniable evidences of internal stran- 
gulation existed as a cause, and for which, after the unavailing employment of 
appropriate remedies, the operation of gastrotomy was performed by Mr. Hil- 
ton. The question then arose as to whether purgatives were so generally cer- 
tain in the majority of cases as to render their exclusive use justifiable,, and 
arguments were brought forward in refutation of such a plan of treatment. A 
case by Dr. Clutterbuck (recorded in the Lancet, 1843, vol. ii. p. 957) was 
mentioned, in which a gentleman, thirty years of age, after violent exercise, 
was suddenly seized with severe pain in the left iliac region, which soon 
shifted to the opposite side. This part soon became tender to the touch, and 
tumefied. Warm baths and purgatives were employed without any effect, and 
subsequently venesection, which was again repeated after an interval of four 
hours. Thirty-six leeches were applied to the abdomen. There was no eva- 
cuation ; the fever was higher, and the pain greater. Croton oil was adminis- 
tered by the mouth, and turpentine per anum ; calomel and opium were given 
freely for twenty-four hours. He vomited, but the matters ejected were not 
stercoraceous, and he was troubled with urgent tenesmus. Several small 
watery evacuations took place, still accompanied by the vomiting, which had 
continued for three days. This symptom ceased for a short time, but soon 
returned, and the bowels were not again relieved, though purgatives and ene- 
mata were employed. The patient died, and, on examination, marks of exten- 
sive inflammatory mischief were found in the abdomen ; the intestines were 
agglutinated, and other marks of disorganization existed. There were ulcer- 
ated openings in the caecum and colon; four or five inches of the lower portion 
of the ileum were sphacelated, and just at the union of the ileum with the 
caecum was found a filbert, complete in its shell, floating in fecal matter. Dr. 
Clutterbuck thought the filbert sufficient to explain all the mischief; for, by 
acting as a local irritant, it set up inflammation, and this became of the general 
and destructive character, which examination after death revealed. This case 
was one of much interest, and particularly as regarded the treatment by pur- 
gatives in cases where inflammatory action existed in the abdomen, either as 



1855.] 



Medical Pathology and Therapeutics. 



197 



the result of intussusception or otherwise. "Would it not be better in such 
cases always to make the inflammatory symptoms the object of the greatest 
attention, and to avoid all drastic purgatives, which he believed were often 
most baneful? Mr. Anderson then stated that Kokitansky, in giving various 
causes of obstruction, says that it may be produced by perforations in the 
mesentery, or by fissures in the omentum altered by disease ; he, moreover, 
particularly objects to purgatives, and advises operation as the sole means of 
relief. Again, Lawrence, in his Treatise upon Ruptures, page 630, states that 
*' the disease, if left to itself, is inevitably fatal. A case was then quoted 
from Sir Astley Cooper's work on Hernia, page 75, showing that strangulation 
does occur in an aperture of the mesentery. The patient died with symptoms 
of internal strangulation ; and " upon inspecting the state of the abdomen, the 
immediate seat of the disease for some time eluded detection, owing to the 
collapsed state of the intestines, but upon a more accurate and minute examina- 
tion, an opening was found through the mesentery, forming a stricture, inclos- 
ing the inferior portion of the ileum, and whi«h decidedly and sufficiently 
accounted for the melancholy termination of the case." Plate xvi. Fig. 1, in 
the same book, is a drawing of the preparation, showing a smaller portion of 
intestine strangulated than was mentioned in Dr. Kidge's case. In a font-note 
at page 77, by Aston Key, the following passage exists: "The possibility of 
affording relief when the abdomen is laid open, and the obstructing cause ex- 
posed, may in some instances be decided in the affirmative ; thus constricting 
bands may be removed, involved portions of gut may be released, an adherent 
convolution be detached, or a gut distended above the seat of stricture be re- 
lieved ; but it is to be borne in mind that gastrotomy will be had recourse to 
only as a dernier ressort, when other remedies have failed, and the symptoms 
have assumed an aspect promising but little chance of success.'^ 

Dr. Ballard mentioned the case of a lady reported to be suffering under 
uterine disease, but which, in reality, proved to be protracted constipation, 
which yielded readily to treatment. He also related another instance in which 
five hundred grains of calomel were given in ten-grain doses, without any spe- 
cific effect beyond removing the constipation. A large quantity of the calomel 
passed unchanged. 

Dr. Ramsbotham alluded to the frequency of a nucleus existing in such cases, 
and quoted an instance where a ball of worsted acted in this manner. 

Dr. Fuller related a case of intestinal concretion in a lady, from whom a large 
quantity of feces passed after months of constipation. He advocated the use 
of electricity and galvanism, and more particularly the employment of nus 
vomica, for the purpose of counteracting the want of nervous action, 

Mr. Borham mentioned a case of a child who had a needle fixed transversely 
across the rectum, causing obstruction, and forming a nucleus. On removing 
it, the obstruction ceased. 

Mr. Weedon Cooke suggested that strychnine had been used long ago, and 
that the credit of its original employment was not to be given to the homoeo- 
paths. He gave an instance of three months' constipation in a boy, aged ten, 
which yielded to injections. 

Mr. Ure mentioned a case of a gentleman who suffered from constipation in 
conjunction with retention of urine. He gave him scruple doses of calomel 
every four hours, a large quantity of which passed unchanged, but the consti- 
pation was entirely removed. 

Dr. Pollock related an instance of constipation arising from over-stimulation 
of the bowels by medicine. This was left off, and an electro-magnetic current 
employed for five months. He strongly advocated the use of small doses of 
aloes, or ten grains of sulphate of magnesia every four hours. 

Dr. Handfield Jones related a case accompanied with severe spasmodic pains 
and flatulent distension, indicating a want of nervous action, for which he gave 
nux vomica. This, in itself, did not produce an evacuation, although it gave 
relief; but the first aperient administered after it produced a motion. 

Mr. Alexander Anderson and Dr. Powell each mentioned a case, the one in 
which a peach-stone, and the other a quantity of cherry-stones, caused obstruc- 
tion and accumulation. 



198 



Progress of the Medical Sciences. 



[July 



Dr. Hamilton Roe was strongly opposed to the use of purgatives in obstinate 
constipation, and stated that calomel and opium, with injections, had always 
proved successful in his hands. 

The President then mentioned the case of an insane gentleman who had 
taken large quantities of carbonate of magnesia, which had formed concretions, 
and could be felt through the abdominal parietes, though a large quantity had 
been removed. He gave another instance of a lady who had suffered from pro- 
longed constipation. Injections were employed, and a large quantity of fecu- 
lent matter came away. He considered that no purgatives could act in such 
cases, and alluded to the value of percussion as a diagnostic, the distended 
intestine being easily detected by this means. — Lancet, March 10, 1855. 

24. Treatment of Acute Rheumatism. — With certain modifications, according 
to peculiarity of case, the basis of the treatment of acute rheumatism now most 
generally pursued in the London Hospitals, consists in the exhibition of the 
neutral salts. It is rare, indeed, to see a case treated, into the prescriptions 
for which neither the acetate, tartrate, or nitrate of potash have entered. The 
congratulatory remarks which are frequently made at the bedside by physicians 
of long experience, must be considered as strong evidence of the good effects 
of the improved practice. The disease no longer needs " the six weeks and 
patience" which it once required. Lemon-juice still holds a high place in the 
esteem of some physicians, among whom we might mention Dr. Burrows, Dr. 
Ridson Bennett, and Dr. Bees; while many others employ it as an adjuvant 
without relying on it alone. That in certain cases it exerts almost no appreci- 
able influence, is generally admitted; while that, in others, it not unfrequently 
cures like a charm, is equally certain. What we desiderate is, an appreciation 
of the class of cases in which it, and in which other remedies are severally most 
likely to be of use. Until that is more or less known, the only refuge is in 
complexity of prescription, an expedient always to be regarded with distrust, 
but not to be shrunk from when required by duty. An illustration of the 
occasional uselessness of lemon-juice was afforded by a man under Dr. Ba- 
bington's care, about a year ago, in Guy's Hospital. He was a man aged 47, 
and was admitted in the third week of an attack of acute rheumatism, for which 
he had kept his bed, and had consumed, during the last four days, no less than 
seven pints of lemon-juice without the least relief. The juice had been ob- 
tained directly from the fruit, of which he had used eighteen large ones daily. 
Dr. Barlow, of Guy's Hospital, is accustomed to state to his clinique, that the 
most rapid recovery from acute rheumatism that he ever witnessed was under 
treatment by the acetate of potash. We may quote the following case as a fair 
example of the usual treatment pursued by that excellent practical physician, 
and also of its average results. The plan of treatment is, however, by no means 
peculiar to Dr. Barlow. H. T., a strong, robust man, aged 33, was admitted on 
the third day of his first attack of acute rheumatism. The disease was severe. 
Ordered to take a draught containing half a drachm of acetate of potash, ten 
grains of the nitrate of potash, ten minims of the vinum opii, diluted with 
barley-water. For nine days he was kept on low diet, and on the tenth the 
improvement was so far advanced that the decoction of bark was substituted 
for the barley-water in the prescription, and a better diet was allowed. On the 
fourteenth day he was convalescent, about the ward, and marked for discharge 
in a few days. — Med. Times and Gaz., 3d March, 1855. 

25. Treatment of Acute Rheumatism hij Large and Frequent Doses of the Bi- 
carbonate of Potash. — Dr. A. B. Garrod, in a paper read before the Eoyal 
Medical and Chirurgical Society, February 13, 1855, observed that he was in- 
duced, in May, 1852, to try a new method of treating acute rheumatism; and, 
finding great success at first, resolved steadily to pursue the plan, and has done 
so up to the present time. The object of his communication has been to record 
the method adopted by him, and also the results obtained in fifty-one cases of 
rheumatic fever, which have been admitted, under his care, in University Col- 
lege Hospital, during the last two years and three quarters. The main part of 
his plan of treatment consists in the administration, in a diluted form, of two- 



1855.] 



Medical Pathology and Tlieraiyeutics. 



199 



scruple closes of bicarbonate of potash, every two hours, day and night, until 
the patient has been free from all articular affection and febrile disturbance 
for two or three days, using local depletion over the heart's region, if any car- 
diac disease is present or threatened. The author then detailed three cases 
of rheumatic fever, illustrating this mode of treatment: The first, a girl, 10 
years old, in which the duration under treatment was five days, the total dura- 
tion eight; the second, a young man, aged 20, with a complication of heart 
disease, where the duration under treatment was eight, the tota,l duration fifteen 
days ; the third, a young woman, aged 18 years, in the fifth attack, the former 
ones having always lasted for a month or five weeks, but which, by the adoption 
of this plan, yielded in nine days ; total duration being but thirteen days, 
four having elapsed before her admission into the hospital. He afterwards 
gave a table of fifty-one cases of acute rheumatism ; and of each patient the 
following particulars are noted: The age, occupation, hereditary predisposi- 
tion ; the number and causes of attack ; the symptoms before admission ; the 
symptoms during treatment; the nature of treatment; and the duration of the 
disease. From these cases, the following deductions are made, viz: that in 
twenty males the duration of the disease under treatment averaged between 
six and seven days, and the total duration between eleven and twelve days ; 
and, in thirty-one females, the disease under treatment averaged from seven to 
eight days, and the total duration between fifteen and sixteen days — giving, in 
all, an average under treatment of seven days and a-half; and, for the total 
duration, about thirteen days and a-half. The author then alluded to the in- 
fluence of the bicarbonate of potash, when administered in large and frec{uent 
doses, upon the difierent organs and functions of the body ; and remarked, that 
it produces neither nausea, vomiting, nor purging ; in fact, no symptom of 
gastro-intestinal irritation. It now induces a strongly alkaline condition of 
the urine, causes it to efiervesce freely, with excess of acid, but does not appear 
to promote an increase in the quantity of the secretion. It appears to render the 
secretion of the skin less acid, sometimes almost neutral. That it acts as a 
powerful controller of the heart's action, reducing greatly the frequency of 
the pulse, but without causing the faintness often produced by digitalis, col- 
chicum, etc. That it probably increases the alkalinity of the serum of the 
blood, and diminishes the coagulability of the altered fibrin occurring in rheum- 
atic fever ; and hence, probably, checking or preventing the deposits of lymph 
on the endo- or peri-cardium. He (Dr. Garrod) stated his opinion, that the 
influence of the bicarbonate was felt not only in shortening the duration of the 
articular affection, but also in preventing or moderating the cardiac disease. 
After enumerating many details of the method adopted, and the value of cer- 
tain adjuncts, as opium, calomel, and occasional general depletion, he proceeded 
to recommend a plan of treatment which, from his experience, he considered 
calculated to insure the greatest amount of success, and thought it probable 
that the total duration of the disease might, on the average, be reduced to 
about ten days, provided that the treatment was adopted early, and no serious 
complication existed. — Med. Times and Gaz., 3d March, 1855. 

26. New Method of Treating Neuralgia hy the direct application of Opiates to 
the Painful Points. — Dr. Alex. Wood, in an interesting paper in the Edinburgh 
Medical and Surgical Journal, for April last, expresses his conviction that " An 
immense improvement was efi'ected in our treatment of neuralgic aifections, 
when M. Valleix directed attention to the fact, that while, on the one hand, the 
superficial nerves of the body are of all others the ones most commonly affected 
with this disease, there are some points of their course in which it is much 
more liable to be seated than in others, although in these, no structural altera- 
tions can be discovered to account for this liability. These points are usually 
more or less morbidly sensible to pressure, even in the intervals between the 
attacks of the sharp lancinating intermittent pain. Avery slight touch in 
these situations is often sufficient to excite acute sufiering ; in other cases, 
however, even firm pressure is borne without any complaint. The points in the 
course of any nerve which are thus liable to be the seat of tenderness are, ac- 
cording to Yalleix :— - 



200 



Progress of the Medical Sciences. 



" 1. The place of emergence of the nervous trunk. 

"2. The point where a nervous twig traverses the muscles to ramify on the 
integuments. 

"3. The point where the terminal branches of a nerve expand in the integu- 
ments. 

*'4. The point where nervous trunks become superficial during their course. 

*' It is perhaps scarcely necessary to remark that all these points are pre- 
cisely those where the nerve tends towards the surface, and therefore where, 
of course, it is the most amenable to local treatment. 

"Acting on the result of this observation, M. Valleix introduced a plan of 
treatment which, as an external remedy, I have largely employed ever since my 
attention was first directed to his work in 1842. 

" It consists in the application of a succession of small blisters over the points 
in the course of the nerves which are painful on pressure. Valleix does not 
recommend, as a general rule, the application of morphia endermically, but 
suggests that it may be attempted with advantage in some cases. I have 
almost invariably employed an ointment containing morphia to dress the blis- 
tered surface, and have been accustomed to ascribe much of the benefit of the 
treatment to this. In some cases, I have seen relief follow the application of 
an ointment containing strychnine to the blistered surface ; but this must be 
used with great caution, as very disagreeable results often ensue from its use. 

" It has frequently occurred to me, however, that a more direct application 
of the narcotic to the afiected nerve, or to its immediate neighbourhood, would 
be attended with corresponding advantage, and as the painful points so fre- 
quently correspond with those in which the nerve becomes superficial, I thought 
this might perhaps be accomplished. In pursuit of this object, I have made 
several attempts to introduce morphia directly by means of acupuncture needles 
and otherwise, but without success. 

*' Having occasion, however, about the end of 1853, to endeavour to remove 
a nsevus by injection with the acid solution of perchloride of iron, I procured 
one of the elegant little syringes, constructed for this purpose by Mr. Ferguson, 
of Giltspur Street, London. While using this instrument for the nsevus, it 
occurred to me that it might supply the means of bringing some narcotic to 
bear more directly than I had hitherto been able to accomplish on the affected 
nerve in neuralgia. I resolved to make the attempt, and did not long lack, op- 
portunity. 

"Miss , an old lady, who had laboured long under gastric and nervous 

symptoms, had suflFered severely for four days from cervico-brachial neuralgia. 
This lady had the idiosyncrasy of not being able to take opium. Of this she had 
warned me many years before, when she first came under my care, and I con- 
sequently never prescribed it for her ; however, once, when she was seen with 
me by the late Dr. J. H. Davidson, he, disbelieving her former experience, pre- 
scribed opium, with the effect of bringing on a severe fainting fit. 

" The narration of her case may date from November 26th. She had not 
been able to sleep for the three previous nights from the violence of the neural- 
gic pain, and was quite exhausted with severe sufi'ering. The usual internal 
remedies, with the exception of opium, had been tried, but without the least 
alleviation of her agony. Under these circumstances, I resolved to put in prac- 
tice the plan which I had so long revolved in my mind. 

"Accordingly, on November 28th, I visited her at 10 P. M. to give the opiate 
the benefit of the night. Having ascertained that the most tender spot was the 
post-clavicular point of Valleix, I inserted the syringe within the angle formed 
by the clavicle and acromion, and injected twenty drops of a solution of muri- 
ate of morphia, of a strength about double that of the ofl&cinal preparation. 

" In about ten minutes after the withdrawal of the syringe, the patient began 
to complain of giddiness and confusion of ideas ; in half an hour the pain had 
subsided, and I left her in the anticipation of a refreshing sleep. 

"I visited her again about 11 A. M. on the 29th ; was a little annoyed to 
find that she had never wakened ; the breathing also was somewhat deep, and 
she was roused with difficulty. Under the use of somewhat energetic stimuli, 



1855.] 



Medical Pathology and Therapeutics. 



201 



however, these symptoms disappeared, and from that time to this the neuralgia 
has not returned/' 

Dr. Wood relates several other cases in which he resorted to this method of 
treatment with advantage. He has satisfied himself, however, that in those 
not unfrequent cases where the disease has a central, not a centripetal origin, 
it is quite useless. 

The following are the conclusions at which Dr. Wood has arrived from his 
experience with this mode of treatment. 

" 1st, That narcotics injected into the neighbourhood of the painful point of 
a nerve affected with neuralgia, will diminish the sensibility of that nerve, and 
in proportion diminish or remove pain. 

" 2d. That the effect of narcotics so applied are not confined to their local 
action, but that they reach the brain through the venous circulation, and there 
produce their remote effects. 

" 3d. That in all probability what is true in regard to narcotics would be 
found to be equally true in regard to other classes of remedies. 

" 4th. That the small syringe affords a safe, easy, and almost painless me- 
thod of exhibition. 

" 5th. That, destitute as we are of any precise experiments as to the applica- 
bility of cellular tissue as a medium for the reception of medicinal agents, the 
experiments made with the syringe show that it seems to offer an excellent 
surface for the absorbent action of the venous system. 

" 6th. That the method now detailed seems as extensively applicable as any 
of the methods of applying remedies to the skin, whether enepidermic, iatra- 
leptic, endermic, or by inoculation.^' 

27. Treatment of Cholera in the Stage of Collapse, hy the Artificial Production 
of Peritoneal or Cellular Dropsy. By Benj. W. Richardson, M. D. — We ex- 
tract the following remarks on this subject from a paper in the Association 
Medical Journal : — 

"The more I have considered the matter, the more thoroughly have I been 
confirmed in favour of the now generally received opinions, that the symptoms 
of collapse are due to the loss of fluid which the body has sustained ; that the 
poison of cholera, like a dose of a violent purgative, has a limit to its action on 
the body ; and that if a patient can sustain the loss caused by the dose of the 
poison he has received, or if he ca,n be sustained artificially from that loss, his 
recovery is to a great degree secured. 

A rapid removal of fluid must not always be considered in regard to quan- 
tity, because all physiological learning goes to prove that a certain balance 
between the densities of arterial and of venous blood must be kept up, to secure 
for the system many processes upon which its existence directly depends. 

*' Now, in cholera, as the serous loss must be derived mainly from the arte- 
rial circuit, it is obvious that a very few copious discharges from the stomach 
or intestines lead quickly to the destruction of the balance that ought to exist, 
speedily arrest the course of the circulation, and of necessity interfere with the 
respiratory process, the generation of animal heat, the function of the nervous 
system, so far as they depend on the blood, and with every other process which 
we consider essentially vital Now, in observing a patient in the col- 
lapsed state of cholera, one sees at once why so much of incessant 

failure attends many of those remedial measures which are commonly adopted. 

" Thus we see that the application of external warmth over and above the 
natural animal temperature, and for the purpose of increasing the heat of the 
patient, is a proceeding at once useless and unphilosophical ; since the body 
does not absorb caloric from without, but makes it from within, and diffuses it 
externally. And, as the coldness of cholera arises solely from the fact that the 
internal chemical process, by which heat is produced, is arrested, it is obvious 
that the only means by which a new supply of heat can be obtained, will be by 
endeavouring to rekindle the natural calorifying influence. It is of course 
strictly physiological to surround the body of a cholera patient with a tempera- 
ture somewhat above the ordinary point of animal heat, or by anon-conducting 
material ; for this is a conservative step, tending to retain such small amount 



202 



Progress of the Medical Sciences. 



[July 



of caloric as may be generated within ; but to do more — to heat the atmosphere 
of the room, to shut off currents of fresh air, without which respiration is a 
nullity — is a system directly opposed to our knowledge of first physiologica;l 
laws. 

" Again, no one who has observed cholera much, can fail to be convinced of 
the frequent inutility of drenching a patient with large amounts of simple 
liquids or medicines, during such times as copious vomiting and purging are 
going on. Eor there can be little or no absorption by a membrane, at a time 
when it is pouring out excreted matters from every point of its surface ; nor 
can we suppose that, even in the last stages of the disease, when from sheer 
want of fluid to exude, the watery evacuations have ceased, the membrane from 
which they have all proceeded, and of whose epithelium immense portions have 
been washed away, is in a very happy condition for the imbibition of substances, 
medicinal or otherwise. And, indeed, we find in practice that even the most 
powerful styptic remedies prove of little avail in arresting the discharge, 
unless given in that early stage of the disease, when their retention is secured. 

"As, then, the loss of fluid from the system is the cause of the collapse, as 
in many cases it cannot be replaced by the natural process of imbibition from 
the intestinal surface, and as the blood cannot circulate and reaction occur, 
without such replacement, there is open before us these plain and simple phy- 
siological problems. Are there any other means by which fluid can be intro- 
duced into the exhausted circulation ? and, if so, which of these is the safest, 
and most calculated to effect the object desired? 

"We have seen that the mucous membrane of the alimentary canal, while 
carrying on an extensive excretory process, cannot invariably be made a medium 
for absorbing fluid to any great extent. Some practitioners have, however, 
believed that the administration of large quantities of fluid by the mouth, during 
the intervals of rest from vomiting, has been attended with benefit ; and there 
surely can be no objection to a plan so reasonable, unless the swallowing process 
should itself excite vomiting, and especially as patients themselves almost in- 
variably crave urgently for drink. 

"The most important step that has as yet been made on the human subject 
towards supplying the exhausted system with fluids, in cholera, is that of 
throwing a considerable quantity of fluid directly into the circulation through 
the veins ; and it cannot be denied that, in practice, this plan has been attended 
with some amount of success. That it should not be generally successful is, I 
think, strictly explainable on physiological grounds. In the first place, the 
plan is objectionable on the mechanical argument, that to throw a large amount 
of fluid through a vein directly into a heart itself exhausted, is sufficient to 
paralyze that organ to a serious degree ; for I have found, by direct experiment, 
that a weakened heart often succumbs instantly from over-distending it with 
blood itself. 

"Another objection to the direct transfusion of water, or of water impreg- 
nated with saline or other materials, into the circulation, is, that such fluid is 
not the proper stimulus for exciting the heart to contraction ; and that, even if 
the heart does contract upon it, and throws it round the pulmonic circuit, it is, 
again, not a substance upon which the process of respiration can properly act. 
When a saline substance, injected into a vein, accomplishes anything, it does 
so, I imagine, by dissolving the half-clotted blood in the cardiac cavities, and 
by carrying the blood, thus diluted, round the lungs. 

" But the last and main obstacle to the success attending injection into a vein 
is, that by this process no such competent amount of fluid can be introduced 
so as to produce a permanent effect ; and, in truth, we too often find in practice 
that, after such injection, the patient only rallies for a brief period, to sink again 
under a continuance of the discharge from the intestines. I do not know what 
is the largest amount of fluid that has ever been injected into the vein of a 
cholera patient ; nor yet the largest amount of fluid that has been known to be 
lost during the disease. 

" Speaking from general observation, however, I may say that the largest 
amount of fluid I have ever heard of as having been injected into a vein in the 
course of a case, is from seven to ten pounds, and the most I have ever seen 



1855.] 



Medical Pathology and Therajjeiitics. 



203 



injected is from three to four pounds ; while I have known a cholera patient to 
pass olf by one vomit from two to three pounds, and repeat this many times in 
the course of three or four hours. 

"In contemplating the subject of transfusing watery matter into the system 
after the modes I have described, the question occurred to me, whether we ought 
to confine ourselves to these modes ; or whether any other means existed of in- 
troducing fluid matters into animal bodies in very large quantities, and in a 
manner which should secure their absorption. This thought led me to look 
back upon the pathological characters and treatment of those diseases in M-hich 
serum is largely thrown out into serous cavities or cellular tissue. I recollected 
that, in cases of this class (dropsical cases), not only were several gallons of 
fluid often thrown out of the circulation into the system without immediate 
danger, but that patients thus situated could tolerate a degree of purgation 
which would absolutely destroy healthy individuals. 

"The idea furnished an important suggestion ; and I consequently commenced 
a series of experiments on animals, which, as they are as yet in an imperfect 
state, I shall only describe in general terms, reserving the particulars for my 
next report, 

" The experiments up to this time have mainly consisted in exhausting dogs 
and cats by starvation and violent purgation with large doses of elaterium, and 
afterwards injecting either their peritoneal cavities or their cellular tissue with 
large quantities of distilled water, at the blood temperature. The results, in 
general terms, are as follows : — 

"I find that either into the peritoneal cavity, or into the cellular tissue, a 
quantity of water, varying from a tenth to a fifth part of the weight of the ani- 
mal may be injected with little risk. The effect of this is to induce a sleepy 
condition, which lasts from twenty to thirty hours, long before which time all 
trace of the injection is lost. If more than this is thrown in, the sleep or rather 
torpor (for the animal only remains quiet, and rouses when spoken to), ends in 
death. 

" Setting aside casualties, I infer from my experiments as they now stand, 
that into the peritoneum or the cellular tissue of a patient in a proper state of 
collapse from cholera, water to the extent of at least a tenth, or even a fifth, 
part of the whole weight of the body might be injected with safety; and that 
the absorption would be almost immediate. 

" The performance of the operation for producing this artificial dropsy is ex- 
ceedingly simple. The instruments required are simply a scalpel, lancet, or 
trocar, a common catheter, and an ordinary enema syringe. If the cellular 
tissue is to be injected, a deep puncture is made with a lancet in some fleshy 
part, the abdomen is the best, and the blunt point of the catheter is then intro- 
duced, and wedged sufficiently far into the cellular substance to allow the skin 
around it to be firmly grasped, so as to keep it steady in its place. The other 
end of the catheter being connected with the enema pump, an assistant very 
gradually throws in the fluid, and, as the tissue distends, gentle compression 
may be made with the hand so as to force on the fluid under the skin. 

" As yet I have had no favourable opportunity of trying the suggestion I have 
here thrown out in cholera; but that it might be put into application in despe- 
rate cases, and might prove advantageous, I have no doubts whatever. The 
advantages of it would be : — 

" First. That an abundant store of fluid would be supplied, which the ex- 
hausted circulating system would rapidly and efiectually take up. 

" Second. That as this imbibition would take place through the capillary 
system, the fluid would enter the veins freely charged with the solid consti- 
tuents of the blood, and would pass to the lungs in a condition suitable for 
respiration. 

" Third. That the process would in no way interfere with the administration 
by the mouth of astringent solutions, or such other medicines or liquids as the 
practitioner might consider indicated. 

" But, although I am thus sanguine on this subject, I wish it to be under- 
stood that the first trial of this process should commence in a case where the 



204 



Progress of the Medical Sciences. 



[July 



patient is in the last stage of collapse, where other remedies have failed, and 
where death is imminent. 

" I should scarcely omit to refer, in conclusion, to the fact (though it is one 
pretty generally understood), that impostors, in feigning diseases, have been 
known to inflate their own cellular tissue or that of their children with air, 
without any harm following ; and the authors of the article, * Feigned Diseases,' 
in the Cycloprndia of Medicine, make special reference to the statement, that 
some French conscripts were known to inject water into their own peritoneal 
cavities to produce a factitious ascites ; while numerous instances have lately 
been recorded, in which, after the operation of tapping, such irritating sub- 
stances as iodine and brandy have been thrown into the peritoneum without 
leading to fatal results." 

28. Injections of Milk or Milk and Water into tlie Peritoneal Cavity or Cellular 
Tissue, or Venous System in Collapse of Cholera. By Wm. Bird Herapath, 
M. D. — In a paper read to the East Surrey Cholera Society, and published in 
the last number of the Association Journal, by Dr. Richardson, a proposal is 
made to inject the peritoneum and cellular tissue of cholera patients in the stage 
of collapse with large quantities of water, for the purpose of rapidly supplying 
the loss of serum experienced by the excessive discharges from the intestinal 
mucous membrane. This extremely philosophical and ingenious suggestion is 
certainly highly deserving of a mature consideration, and a careful digest of 
properly conducted experiments. But it has occurred to me, whilst reading 
these remarks, that the injection of a fluid more closely approaching the cha- 
racter of serum in its chemical constitution, would be more likely to give per- 
manent benefit, and avoid the chances of destruction of the blood-corpuscles, 
occasioned by the difference existing between the specific gravity of their con- 
tents and of the rapidly imbibed water. 

The most readily obtained liquid, having all the qualities we can desire, is 
most assuredly cow's milk ; it is always at hand in any quantity, whilst its 
tendency to coagulate may Idc obviated by adding a little solution of carbonate 
of soda or potassa ; perhaps about one scruple of the salt to a pint of milk would 
be sufficient. 

The only difficulties about the matter would be the adulterations to which it 
may be subjected by fraudulent dealers, and the accidental presence of foreign 
bodies. 

The entrance of foreign bodies into the circulation, or into the cavity of the 
peritoneum, or the meshes of the cellular tissue, may be easily prevented by 
attaching a fine muslin or gauze filter, or sieve, to the mouth of the injecting 
syringe. It remains to be proved whether this fluid would be absorbed by 
the peritoneal vessels as readily as water, or with sufficient facility to be of 
service. 

The specific gravity of good pure milk varies from 1.041 to 1.033 or 1.020 ; 
serum varies from 1.026 to 1.037, and even 1.050, according to the presence of 
health or disease. Now to produce the difference in specific gravity required 
by the laws of endosmosis to act in a state of health, water may be added to 
the milk. But the viscidity of cholera blood would assuredly indicate an increase 
in the specific gravity, and no dilution would be 7iecessary in this disease ; but 
if it were adulterated with water only, it would be a matter of no great im- 
portance. 

It seems highly probable that milk, or milk and water, would be a much more 
successful fluid for this purpose than water only, and would certainly offer 
many great advantages, especially if the injection were to be made directly into 
the venous system, as the corpuscles of the blood do not suffer any material 
alteration in form, when examined microscopically, after dilution with milk ; 
they suffer nothing from the admixture, especially if the milk is obtained from 
an animal of the same kind as the blood experimented on, and if the milk used 
be pure and unmixed with water. 

I apprehend also that the introduction of an albuminous constituent is essen- 
tially necessary, to supply the waste of this vital pabulum experienced during 
the exhaustive discharges of this disease. 



1855.] 



Medical Pathology and Therapeutics. 



205 



It is quite a question whether the subsequent symptoms and fever, exhibited 
during the recovery from collapse, do not depend as much upon the loss of the 
albumen and salts of the serum, as upon the great difference subsequently 
existing in the relation betv^^een the quantity of the solids and watery jiuid of 
the blood. 

The chemical constitution of '-milk does not differ very materially from that 
of the chyle obtained by healthy digestion, which would of course be the only 
means nature would employ to regenerate slowly the lost liquor sanguinis. 

Art physiologically directed comes to the aid of nature, and by employing 
her own Divine laws, assists her early efforts and wonderfully aids the cure — 
gains time, an element of vital importance in this marvellously rapid and fatal 
disease. 

Nature would then merely have to regenerate the lost epithelial cells, which 
would of course be a work of time ; and no efforts of art could remedy this 
defect ; if the amount of the epithelial exfoliation had been very excessive, the 
exhaustive discharges of the choleraic diarrhoea w^ould go on in spite of all our 
injections ; for the intestinal mucous membrane would then be in the condition 
of the dermis denuded of its epidermis by artificial vesication ; exosmosis must 
occur by serous transudation until the protective covering had been reformed, 
when endosmosis would again recommence from the re-establishment of the 
physiological action of these wonderful cells. — Association Medical Journal. 

[In recording the above communication, we would merely allude to the effects 
which have followed the use of milk in the only instance, we believe, in which 
it has been injected into the human body — for hydrocele ; in this case the milk 
coagulated, gave rise to serious ill consequences, and had to be removed by 
free incision, in the form of curds, mixed with a great quantity of pus. Sir 
Astley Cooper, who records this circumstance in his " Lectures,^^ merely adds: 
" Be upon your guard, therefore, against making experiments of this kind.'' 
— Ed.] — Dublin Hospital Gazette, September 15, 1854. 

29. Treatment of Spermatorrhoea. — M. Trousseatj thinks that the advantages 
of Lallemand's _por^e caustique have been considerably overrated, and that there 
are only certain cases in which its use is productive of benefit. It is very use- 
ful where chronic urethritis co-exists with the spermatorrhoea ; but where that 
is absent, he thinks we ought to trust to other modes of treatment more suited 
to the cause of the disease. 

The excessive debility induced by spermatorrhoea demands our most serious 
attention. If, in serious cases, we find neither urethritis nor cystitis present; 
if we discover neither calculi nor ascarides, nor any other thing which can 
explain the persistence of the emissions, we ought to ask ourselves whether 
the disease does not depend upon a condition of the vesiculse seminales analo- 
gous to the spasmodic state of the bladder in certain forms of incontinence of 
urine. Puerile enuresis is not due to atony of the bladder, or to any undue 
accumulation of urine, but to a spasmodic condition of the bladder. The same 
phenomenon occurs in the vesiculse seminales ; and belladonna, which acts so 
beneficially in the case of the bladder, is also very useful in this other spasmo- 
dic condition. M. Trousseau prescribes accordingly, in such cases, powders 
containing each 1 centigramme of the powdered root of belladonna, mixed with 
sugar. He orders one to be taken daily during the first week of treatment ; 
two daily during the second, and so on until the patient experiences a sen- 
sation of dryness in the throat. At the same time, he orders frictions of the 
perineum with an ointment composed of 10 grammes of the alcoholic extract 
of belladonna to 20 grammes of axunge. If necessary, he also uses supposi-. 
tories containing each 10 centigrammes of the extract, belladonnas. 

M. Trousseau doubts the utility of cold hip-baths in this affection. They 
may do good the first time they are used, but, although they may temporarily 
arrest venereal excitation in nymphomania and priapism, this calm disappears 
on the occurrence of reaction, and the evil is increased. 

Heat acts in an opposite manner. Hence M. Trousseau believes that, in cases 
where erotic feelings are conjoined to spasm of the vesiculoe seminales, it is the 
best sedative which we can employ simultaneously with belladonna. The 
No. LIX.— July 1855. 14 



206 



Progress of tlie Medical Sciences. 



[July 



form in -which he employs it is that of bags of heated sand, which he applies 
to the perineum for a few minutes, morning and evening. The simultaneous 
administration of lupulin may be very beneficial ; but, where we desire decided 
anaphrodisiac effects, M. Trousseau recommends, on account of the certainty 
and efficacy of its action, the bromide of potass, in doses of from 15 grs. to^ss. 
daily. — MontJdy Journ. of Med. Sci., March, 1855, from Jourji. de Med. et de 
Chirurg. Prat., December, 1854. 

30. Gallic Acid in Pyrosis. — Dr. Bayes says that, in pyrosis, where this dis- 
ease is unaccompanied by extensive ulceration, or organic malignant disease of 
the stomach, or by disease of the liver, the most marked benefit will follow the 
use of the remedy. Gallic acid, here, not only checks the secretion with a 
certainty and rapidity he has never seen follow the administration of any other 
remedy, but it gives general tone to the stomach, increases the appetite, and 
(what I very little expected when I first used it) in many cases removes con- 
stipation. This I can only account for on the supposition that the relaxed atonic 
state of the stomach which favours pyrosis is continued throughout the ali- 
mentary canal, the constipation in these cases arising from want of power in 
the muscular coats of the intestines to expel the feces. The want of tonicity 
is remedied by gallic acid. — Association Med. Journ. 

31. Sal Prunella in Polydipsia. — M. Debout observes that polydipsia is an 
affection of more frequent occurrence than would be supposed from the silence 
of most pathologists. Scarcely a year passes without examples being met with 
in the Paris hospitals ; the patients usually, however, applying for some coin- 
cident affection. So great has been the difficulty of relieving it, that from 
among twenty-six cases, collected by M. Lacombe from different authors, only 
two were cured, and perhaps not permanently. 

The slight specific gravity of the urine, and the absence of sugar, distinguish 
the affection from diabetes, and there is no example of simple polydipsia having 
terminated fatally. Its pathogenetic conditions being unknown, we can only 
treat it empirically, and M. Debout relates the case of a man, aged 24, who, the 
polydipsia having commenced three years previously, after exposure to the sun 
during great exertion, drank between four and five gallons of fluid per diem. 
When seen by M. Debout, he was the subject of acute rheumatism, and. 450 
grains of nitr. potassse in four quarts of tisane were ordered him in the twenty- 
four hours. For the first time since three years, so small a quantity of fluid 
sufficed to stay his thirst; and both rheumatism and polydipsia became cured 
together, no return having occurred when he was seen a year later. 

On searching, M. Debout found that sal prunella had already been given by 
Rivierius and T. Frank, and in his next cases he administered this in doses of 
60 grains per diem. Rapid melioration was almost always the result ; and, 
although this has not been usually permanent, it has again been procured on 
recurring to the remedy. At all events, nitrate of potass would seem to be the 
best remedy yet discovered, and sal prunella the best form in which it can be 
given. — Bulletin de Therapeutique, torn, xlviii. p. 97. 

32. Pomade of Proto-SidpJiafe of Iron in tlie Treatment of Skin Diseases. — M. 
Devergie recommends the use of this remedy in those affections of the skin 
which in their essence are secreting, and which generally occur in lymphatic 
temperaments and constitutions, observing that its curative results are espe- 
cially decided in eczema and eczema impetiginodes. Similar success attends 

, their use in impetigo and intertrigo; and in eczema of the scrotum, often an 
obstinate affection, he had met with remarkable success from this application. 
It is a useful application, also, to the ulcerations which succeed to the vesicles 
or pustules of rupia and ecthyma cachecticum. It is useless in the scaly affec- 
tions, and absolutely injurious in the bullge, and in those essentially vascular, 
as pemphigus and herpes with large vesicles. It is also injurious in acute 
ecthyma, acne rosacea, and raentagra. In addition to being resolvant, M. De- 
vergie considers that it modifies the vitality of the diseased tissues, a property 
which does not belong to tannin, oxide of zinc, calamicus, or alum. The fol- 



1855.] 



Medical Pathology and Therapeutics. 



207 



lowing is the formula employed: Axunge 30 grammes (seven and a half 
drachms) ; proto-sulphate of iron crystallized and washed, 50 centrigrammes 
to 1 gramme (eight to fifteen grains) ; dissolve the salt in a few drops of water, 
and incorporate it immediately with the axunge. Keep it from contact with 
the air. — Bulletin Gen. de Therap., 1854, p. 553. 

33. Employment of Alkaline Carbonates in the Treatment of Membranous An- 
gina. ~M. Marchal de Calvi advocates the employment of alkalies in this 
sometimes most intractable disease, and cites cases treated by the bicarbonate 
of soda, in which the recovery was rapid, immediately following its adminis- 
tration. In the first case, the mucous mxcmbrane, at the back of the throat, 
was very red and oedematous; the mucous mem.brane, too, covering the palate 
and tonsils, was covered with stripes and patches of false membrane. This 
exudation was beneath the epithelium, for it could not be scraped off with the 
nail. Deglutition was performed with considerable pain. Twelve leeches were 
first applied to combat the inflammation, and three drachms of bicarbonate of 
soda were ordered to be divided into twelve packets, one to be taken every half 
hour, in a spoonful of water. Upon returning, after an absence of four hours, 
he found that the leeches had drawn a large quantity of blood, which was 
decidedly less plastic than natural. Upon examining the throat, the false mem- 
brane was found to have disappeared entirely. This the author attributes to 
the administration of the bicarbonate of soda, whose action he thus explains. 
Its first or chief action is to render the blood less plastic. It is with this object 
in view that the medicine is prescribed ; but there seems to be another mode of 
action in this peculiar disease, which M. Suresure has supposed likely to exist, 
viz : a local action ; which may account more satisfactorily for its rapid action 
in the case just recorded. — Dublin Hosp. Gaz., 15th May, from Gazette Medicate 
de Paris. 

34. Inlialations of the Fumes of Opium in Coryza. — Dr. Lombard, of Geneva, 
has found that in those severe cases of coryza which are accompanied by great 
pain and sense of weight in the frontal sinuses, the inhalation of the fumes of 
burnt opium affords the patient the most marvellous and speedy relief. The 
pain ceases as if by enchantment, and the patient passes from a state of misery 
into one of comfort. Dr. Lombard recommends a few grains of powdered 
opium to be thrown upon a slip of metal, previously heated in a spirit lamp ; 
and the patient is desired to hold his head over, and forcibly to inhale the 
fumes of the drug. — Gaz. Medicate, July, 1854. 

35. Chloroform for the Treatment of Lead Poisoning. — Chloroform is recom- 
mended by M. Aran, Physician to the Hopital St. Antoine, in Paris. He has 
just published a somewhat lengthy paper on its use, in which he gives some very 
interesting illustrative cases. One of these occurred in a house painter, aet. 31, 
who was affected with lead colic for the second time, after having followed his 
trade for twenty years. There were obstinate constipation, bilious vomiting, pain 
in the epigastrium, tormina, scanty urine, and a very low pulse — only 48. A com- 
press, on which nearly a drachm of chloroform had been poured, was placed on 
the umbilical region, and retained there for several minutes. In spite of the sen- 
sation of heat and burning occasioned, immediate relief was experienced by the 
patient. In addition to this, a sulphureous bath tvas ordered; a mixture con- 
taining 30 drops of chloroform was administered ; and a domestic enema was 
prescribed, to be followed by a small clyster, with 20 drops of the angesthetic in 
it. This treatmient was continued for a week with great benefit, the chloroform 
being given morning and evening; and sixteen days after admission the patient 
was discharged cured. Kather an interesting incident occurred in this man's 
case; he swallowed, one day, by mistake, nearly an ounce (30 grammes) of 
chloroform. Symptoms of narcotic poisoning appeared, but the patient re- 
covered satisfactorily. Several other cases are given, in which the same treat- 
ment proved very efficacious. 

M. Aran says that the compress saturated with the chloroform should be 
covered with dry compresses, and that it should be allowed to remain in contact 



\ 



208 Progress of the Medical Sciences. [July 

■with the skin from two to five minutes. After the preliminary large doses, the 
following mixture should be used: R. chloroformi gtt. 20-50; gum. tragacanth 
5j ; syr. simplic. ; aqusg ^iij. Misce. Dose, a teaspoonful frequently. He 
gives the following formula for the chloroform enema: R. Chloroformi gtt. 
20-50; gum, tragacanth ^ij; ov. vitelli, j ; aquee ^iv. Misce. 

The patient should be desired to endeavour to retain this enema as long as 
possible. — Monthly Journ. Med. Sci., April, 1855, from L' Union MedicaJe, Jan. 
1855. 

36. Iodide of Potassium for Cure of Lead Poisoning. — It has been asserted 
by MM. Natalis Guillot and Melsens that the administration of the iodide of 
potassium is the best means for ridding the system of lead and mercury, inas- 
much as the insoluble compounds which the salts of these metals form with 
the organic substances are all soluble in the iodide of potassium, which is a 
salt very easily and rapidly eliminated from the animal economy. Mialhe de- 
nied these assertions, which were founded on experiments made on dogs. M. 
Malherbe, chief physician to the IIStel-Dieu, at Nantes, has recently tried the 
drug in some cases of lead poisoning, with great benefit. He never gave more 
than 15 grains daily, but often much less. His experience of the remedy has 
not been sufficiently extensive to enable him to arrive at definite conclusions ; 
but he thinks, from the trials he has made of -it, that the following deductions 
are warrantable: — 

1. In lead poisoning, elimination of the metal takes place naturally by means 
of the urinary organs, which is probably due to the influence of the alkaline 
chlorides contained in the animal fluids, as has been thought by M. Mialhe. 
But this eliminative process is not sufficiently rapid to procure a spontaneous 
cure of lead poisoning. 

2. This elimination of lead by the urine is rendered much more active by 
the use of the iodide of potassium ; the excretion of the phosphates by this 
channel is also considerably increased; and these salts yield an insoluble resi- 
due which contains the greater part of the eliminated lead. 

3. Although lead is not naturally eliminated by the saliva, the iodide of 
potassium seems capable of occasioning its discharge through this medium. 

Malherbe gives the following rules for the rational treatment of lead poison- 
ing, in which he has arranged the remedies according to their relative import- 
ance, and not in the order in which they should be administered, which must 
necessarily vary in different cases. The indications are : — 

1. To eliminate the lead contained in the economy by means of iodide of 
potassium, which should be administered methodically, and should be given as 
long as the urine and the saliva give the reactions of the metal. 

2. To cleanse the cutaneous surface by means of sulphureous and soap and 
water-baths ; and to purify the mucous surfaces by the internal use of the 
preparations of sulphur and by purgatives. The latter medicines, by inducing 
abundant bilious evacuations, doubtless eliminate a part of the lead contained 
in the liver; but they cannot reach those portions of the metal which are com- 
bined with the tissues of other organs. 

3. To calm hypersesthesia and nervous symptoms in general (as epilepsy, 
delirium, convulsions, coma) by narcotics, and especially by belladonna, which, 
in addition to its sedative properties, is possessed of a cathartic action which 
often renders the employment of purgatives unnecessary. 

4. To combat paralysis by means of strychnia and electricity. — Monthly 
Journ. Med. Sci., April, 1855, from Gaz. des Hopitaux, 21st Dec. 1854. 

37. Employment of Wi7ie as an Enema. — M. Aran observes that, in many 
cases of dyspepsia, chlorosis, phthisis, and convalescence from severe disease, 
the use of wine is strongly indicated, whilst the heat and irritation of the di- 
gestive organs it induces absolutely prevent its employment. Having found 
vinous enemata of great utility in obstinate diarrhoea, he tried them in various 
other cases, and for the last three or four years he has administered them 
whenever slow convalescence has been united with irritability of the digestive 
organs. He has also obtained great and unexpected advantages in phthisis, 



1855.] 



Surgery. 



209 



having at first administered the wine on account of the accompanying diar- 
rhoea. When the disease is advanced, little, or only temporary, benefit results; 
but, when given at an earlier period, and associated with cod-liver oil or other 
means, the wine does exert a salutary influence that merits attention. In gas- 
tralgia, while the general debility seems to indicate the use of tonics, yet wine 
cannot be given, even in smalt quantities, without exciting a sensation of 
burning; but in several examples of this the vinous lavements have not only 
restored strength, but have so diminished the gastric irritability as to allow of 
a little wine being taken with the food. Another form of dyspepsia alike sus- 
ceptible of benefit is vomiting, with the rejection of alimentary matters — the 
strength and embonpoint rapidly returning under the use of the enemata. 

But the affection in which M. Aran has been most surprised at the amount 
of success obtained is chlorosis. Influenced by the so prevalent opinion that 
iron is the specific remedy, he at first gave it in conjunction ; but he afterwards 
omitted it, only prescribing, besides the wine, general frictions with an ammo- 
niacal liniment, and a powder consisting of bismuth, rhubarb, and valerian. 
In a few days, the patients seemed to have recovered their normal health just 
as if iron had been given, and that even in severe cases. In their relation to 
iron, cases of chlorosis may, indeed, be divided into three categories. In the 
first and most numerous, iron properly administered furnishes a durable cure. 
In others, a rapid amelioration ensues, which is followed by a relapse on its 
discontinuance. Temporary amendment attends its resumption, and so on for 
j'-ears, iron thus becoming a constant necessity. Thirdly, there are not a few 
cases in which iron fails altogether, or in which the amelioration never rises 
to the dignity of a cure. M. Aran has also advantageously employed the in- 
jections in various other conditions characterized by debility, and especially in 
paludal, syphilitic, or cancerous cachexy, in some cases of anasarca, and in 
difierent circumstances in which alcoholic stimuli are indicated. 

The lavements are found to act advantageously, in proportion as the indi- 
viduals have been previously unaccustomed to alcoholic drinks. Thus, they 
are, in general, more useful in women than in men, more still in young girls, 
and more so in the inhabitants of the country than those of Paris. Until the 
patient becomes accustomed to them, they induce a kind of drunkenness, but 
very different from that following the swallowing of wine ; and if the enema 
be given in the evening, so that the patient may afterwards remain quietly re- 
cumbent, refreshing sleep ensues. It is to be remarked, that effects are pro- 
duced by a dose of wine that, if swallowed, would induce little eft'ect. It is 
sufiicient, in slight cases, occurring in impressionable persons, to employ 150 
grammes; but, in obstinate cases, 250 to 350 grammes may be required. In 
the chlorotic, it seems much to hasten the cure to divide the dose into two 
parts, administering one morning and evening. In general, from 150 to 250 
grammes suffice, and it is better, if the wine is rich, to commence its use by 
diluting it with water. Immediately before giving the enema, the rectum 
should be emptied by a lukewarm injection, and the wine should be employed 
tepid, so as not to induce contraction of the rectum. At first, the patient 
should lie down, and endeavour to retain the fluid; but those who are accus- 
tomed to the treatment retain it with little trouble in any position. — Med, 
Times and Gaz., March 17, from Bidl. de Therap., 1855, t. xlviii. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

38. Discussion on the Curability of Cancer, and its Diagnosis by means of the 
Microscope. — [We continue, from p. 520 of our preceding number, the interest- 
ing discussion, at the Imperial Academy of Medicine, relative to this subject.] 

Nov. 7, 1854. M. Velpeau said: At the commencement, I advanced two pro- 
positions : 1st. That cancer was sometimes curable ; and, 2d, that certain cases 



210 



Progress of the Medical Sciences. 



[July 



of cancer could be recognized without the aid of the microscope. To these 
questions I mean now to confine myself, seeing that the discussion has em- 
braced too many topics for me to overtake ; and I intend also to state by what" 
observations and researches I was led to form the opinions I then expressed. 

I have said that the " cell" is not the specific element of cancer, as these 
gentlemen thought; and that there are epithelial cancers which contain no cells. 
M. Larrey must have spoken unthinkingly when he appealed to the unanimity 
of microscopists in this matter, for certain of them admit what others deny. 
Contrary to the opinion of Lebert and Broca, it is admitted by Mandl, Yirchow, 
Bennett, Paget, and others, that there are epithelial cancers without cells. 
Microscopists are not all agreed, because cells do not exist in all cancers. 
There is some other thing in cancer of greater importance than the cell ; and 
in the blood of patients having the cancerous cachexia there certainly exists 
something peculiar to the condition which we do not as yet know. The cell 
is one of the manifestations and material characteristics of cancer: but it is not 
the principle of the disease, or the malady itself. This cancer-cell has been 
found elsewhere than in cancers, and it existed in a non-cancerous portion of 
the vesical mucous membrane, lately exhibited to the Societe de Biologie. It 
appears to me not to be a sufficiently constant characteristic to enable us to 
distinguish the different varieties of tumours, and, therefore, I have tried to 
diagnose them by other signs. I have examined a very large number of can- 
cers, and admit the occasional, but by no means the constant existence of the 
so-called cancer-cells. It may be said that the cases where the cells were ab- 
sent were not true cancers ; be it so, I am willing to set them aside as doubtful. 
But I have seen tumours containing cells which were not cancerous. It has 
been asked whether I consider them to have been benign on account of their 
non-recurrence, and it has been objected that I cannot base my opinion on this 
character, if I admit that cancer is sometimes curable, and consequently does 
not consta,ntly recur : but it is not from the non-recurrence of the tumours 
alone that I judge, but from the tout ensemble of their physical characters and 
clinical signs. 

I af&rm, then, that cancer-cells have been demonstrated in non-cancerous 
growths, and that they are often absent in true cancers. 

. M. Malgaigne has suggested that in these cases of cancer without cells I have 
mistaken fibro-plastic for scirrhous tumours. This I have taken special care 
to avoid doing, and when I speak of cases of schirrus, they were undoubtedly 
true cases of it. It has been said that the cells were not found, because the 
whole tumour was not examined. I have never attempted to puzzle the 
microscopists, and I have always given them the entire tumours for examina- 
tion. Cancerous tumours, like other pathological specimens, are not equally 
diseased throughout their whole extent ; there is generally a central portion 
in them in which the disease is most marked ; but if we have a section made 
through this part, it is just as good as if we had the entire tumour. If cancer- 
cells are not found in such a section, they are certain not to exist elsewhere. 
I have cited cases of tumours, which contained no cancer-cells at first, recurring 
afterwards, and exhibiting these cells in their structure. I have seen two or 
three such cases. In one of these, a man had a cancerous tumour, a portion of 
which was removed and sent to M. Lebert for examination. Finding no cells 
in it, he pronounced it to be benign. M. Richet, therefore, operated on the 
patient; things went well at first, and the cicatrix looked healthy; but ere long 
the tumour returned and killed the patient. The second tumour contained 
cancer-cells. Again, a woman had a mass of vegetations on the left breast, 
which resembled neither encephaloma, scirrhus, nor fungus. I removed one 
of these vegetations, and found that it contained no cancer-cells; but I was not 
therefore convinced that it was not a cancer. The woman returned after some 
time, having the ricjlit breast affected with all the most marked characters of 
cancer — partial indurations, and retraction of the nipple. She soon died of the 
affection. M. Robin found cancer-ceils in the tumour of the right breast, and 
also numerous nodules, in the lungs and liver, containing cancer-cells. Can 
we say that in this case the tumour of the right side was a cancer, while that 
of the left was non-malignant? Certainly not. Moreover, the cells were found 



1855.] 



Surgery. 



211 



on the side on which the tumour was least degenerated. M. Leblanc has at- 
tempted to explain these differences, by admitting the existence of "mixed 
tumours and he believes that cancer may become developed in a tumour not 
primarily malignant. Microscopists, however, deny the transformations of tu- 
mours. I myself am doubtful as to whether benign tumours may degenerate^ 
and I would not be understood either to affirm or to deny it; for facts have led 
me to believe that such a change may be quite possible. 

It appears to me, then, 1st, that there are cells without cancer ; and, 2d, that 
there are cancers without cells ; and if these facts be once admitted, they go very 
far to negative the assertions of the microscopists. A new definition of " can- 
cer" is asked ; but the remodelling of definitions is a barren and unprofitable 
work. It is far easier to attack an old definition than to make a new one, 
even when it relates to something we understand very well. For example, I 
should be puzzled to define M. Robert with exactitude, yet I can quite well re- 
cognize him. I would characterize cancer as a malady, which may appear as 
an excrescence, a tumour, an ulcer, or a fungosity ; the specific nature of which 
is, when once established, to spread, to invade diseased tissues, and, finally, to 
cause death. 

Let us look now at the tumours which the microscopists refuse to admit as 
cancers. They deny that epithelial tumours are cancerous, because their tis- 
sues are homomorphous, and such a structure, they say, cannot be malignant. 
They allege that these tumours do not recur, or if they do, that they affect 
only the original spot, but that they do not affect the lymphatics, or become 
generalized. Every-day experience, however, shows that these tumours may 
recur, not only on the original site, but also in the glands; and that their recur- 
rence, far from being exceptional, is very frequent. Hence, M. Lebert and other 
microscopists have considerably modified their first opinion. Yet they affirm 
that epithelial tumours never, like cancer, become generalized. Now, M, 
Robert himself has adduced instances of their generalization ; and others are 
recorded by Paget, Yirchow, and Rokitansky, in which they become developed 
in the heart, lungs, and liver. Yet this, say they, happens very rarely. I do 
not know ; but whether it occurs often or seldom does not at all alter the ques- 
tion. We remove a small tumour of this sort from the lip ; at the end of two, 
three, six, or twelve months, we find that it returns ; again we excise it, and 
again it recurs. Finally, we dare not touch it ; and it kills the patient as surely 
as cancer. Wherein lies the difference between them ? 

Again, as to fibro-plastic tumours. To constitute them a distinct group from 
cancers, the microscopists have been obliged to class with them many tumours 
to which they have no analogy. How can fibro-plastic tumours, which prove 
fatal to the patients, be confounded with simple glandular hypertrophies ? and 
in what respects do they resemble each other? Although the anatomical struc- 
ture of both may be similar, there doubtless exists in them some unknown 
element which constitutes their essential difference. M. Lebert has said that 
these tumours, like the epithelial, do not recur, or if they do, that it is only 
locally ; but I have shown that gentleman many instances of their reproduc- 
tion in the viscera. M. Robert has cited cases to prove the non-recurrence of 
fibro-plastic tumours ; but — so great is the blindness which an adherence to a 
preconceived idea occasions — all these cases occurred before the use of the mi- 
croscope. For thirty years I have constantly applied the great law of Bichat, 
cited by M. Robert, to everything in pathological anatomy. But, in pathology, 
anatomy, though very necessary, is not all-important; for we must also take 
into consideration the oftentimes obscure nature and causes of disease. There 
exists in cancer something special, something not anatomical, which has 
hitherto escaped all the investigation of our senses, and of which the micro- 
scopists have taken no note. 

Here, then, is my basis for the distinction of tumours. Cancerous tumours all 
possess one character in common : they have all a tendency to destroy the tissues 
by becoming generalized. All that can be said against this proposition lacks 
demonstration, and proves nothing. 

I turn now to the question of its curability ; and the first difficulty that 
presents itself is diagnosis. And, first of all, I would remark that it has been 



212 



Progress of the Medical Sciences. 



[July 



said that I lay pretecsions to infallibility of diagnosis, and that I boast I am 
never deceived. God knows that I lay claim to no such lofty pretensions. I. 
have merely said that there are certain tumours, v^^hose clinical characters are 
so well marked that it is impossible for any one to be deceived. I have taken 
notes, for the past year, of 120 cases of tumours ; 66 of which were cancers. 
Among these 66 cases, I have removed 49 cancerous mammse ; in every case, 
the extirpated tumours were examined by the microscope, and in every instance 
the microscope confirmed the diagnosis I had made before the operation. Let 
me add, however, that I have never alleged that a correct diagnosis can always 
be made. When I say that in certain cases I cannot be deceived, I allude to 
those in which the characters are so well marked that any surgeon could re- 
cognize them. 

I come now to the important point. Why may not cancer be curable? 
When I advanced facts supporting the curability of cancer, it was said that 
they were inconclusive, because they were anterior to the use of the microscope. 
But when, in the 49 cases I have mentioned, which were microscopically exa- 
mined, my diagnosis was in no instance wrong, how can it be said that I was 
deceived before the introduction of the instrument? As regards my statistics, 
it has been said that 20 cures in 50 cases is too good to be true ; but I have not 
alleged that I cured 20 out of 50 patients, but out of 200, one-half of whom 
died. (Here M. Velpeau cited several cases of persons who were cured of can- 
cer ; that is to say, who never had any recurrence of the disease for a greater 
or less number of years after the extirpation of a cancer — cases which were 
almost all witnessed and examined by the microscopists.) These facts, said he, 
are authentic ; and the curability of cancer cannot be denied. M. Robert has 
alluded to the case of a lady operated on in 1850 ; but he has not observed 
that, in detailing this case, I made reservations in respect to it. 

As to relapses recurring long after the operation, as after ten, fifteen, or 
twenty years, may we not inquire whether or not it is possible that cancer, 
like other diseases, may become twice manifested in the same individual, without 
this being looked upon as a recurrence? I am always asked why we are un- 
willing that cancer should be curable? and what interest microscopists have 
in maintaining that it is so ? I have never been able to understand it. Sta- 
tistics, and the authority of highly respectable names — as Munro, Boyer, etc. — 
have been cited in support of the incurability of cancer. But the statistics 
of Munro and Boyer are of great value ; those of Hill and Flajani do not mili- 
tate against mine ; and as to the recent ones of MM. Lebert and Broca, they do 
not appear to me a whit more conclusive, as many of the patients enumerated 
in them were entirely lost sight of. 

What we seek here is truth ; but we should not make the obtaining of it 
depend upon a mere theoretical opinion, since theory alone has given rise to 
the unbelief in the curability of cancer, which I so much deplore. As to the 
microscope, I maintain that it has done good service to science ; I believe that 
it will render still more; but I am confident that it has also committed seve- 
ral errors. I accept all the new facts which it has revealed to us ; and I only 
contest the false or doubtful explanations which have been given to them. 
And as regards the question at present under debate, I think that its resolu- 
tion should be made with great caution and reserve, inasmuch as there probably 
exists some special element with which we are not yet acquainted. I have 
ever encouraged, and I will contintie to encourage fresh researches ; but I will 
only accept as true what I find to be satisfactorily demonstrated. I hail the 
march of progress with unmixed delight, so long as the car of science is pro- 
pelled, but is not overturned. 

Nov. 14, 1854. — The secretary read the following letter, addressed by M. 
Mandl to the president: — 

" Mr. President: M. Velpeau, in his last address, has done me the honour 
to class me among the microscopists who do not admit the existence of charac- 
teristic cancer-cells. I beg to say a few words to the Academy on my reasons 
for so thinking : — 

" Shortly after Mliller, in 1839, discovered cells in cancerous tumours, I pub- 
lished my observations in the Archives de Medicine. But in 1843, I owned 



1855.] 



Surgery. 



213 



that the sanguine hopes which I had at first formed of the advantages to arise 
from the employment of the microscope in the examination of such pathological 
specimens, had not been realized ; and my researches since then have confirmed 
this opinion. I had soon abundant opportunities of examining tumours M^hich 
had appeared to clinical observers to be cancerous, from their origin, progress, 
and fatal termination, but vrhich' contained none of the cells considered by 
Lebert to be characteristic of the malady. I can remember cases of epithelial 
and fibro-plastic tumours ; but I would more particularly direct attention to 
cancers of the retina. In four out of five tumours of this last kind, extirpated 
by Sichel and B6rard, it was impossible to discover any specific cell ; and yet 
subsequent general infection left no doubt as to their malignant character. 

" On the other hand, in the cells found in cancerous tumours, I have not 
observed the characters which they are said to present in the majority of cases. 
According to M. Lebert, the nucleus of the cancer-cell has always a mean dia- 
meter of, from the y^-{}oth to the jofo^^ of a millimetre. {On Cancer, p. 30.) 
Yet, in encephaloid tumours, I have found the nuclei not above the y/iygth or 
the jo^oo of a millimetre; and in such cases it is impossible to distinguish them 
from the other nuclei of normal tissues. Again, as to nucleoli, I have often 
found their characters very imperfectly marked. In M. Lebert's work, we find 
examples of these inferior dimensions in cancers of the bones, the stomach, 
etc. As good, and even better observers than M. Lebert, believe that it is neces- . 
sary to take into consideration all the elements, and also to know the history 
of the disease, before pronouncing a judgment upon its nature. Does not this 
show that the cell is not sufficiently characteristic of cancer? 

" The truth of this is proved, not only by observation, but also by the laws 
governing histogenesis. It seems to me that, in order to solve the problem 
which we are at present studying, it is indispensably necessary that we engage 
in the comparative study of normal histology, and especially in the study of 
the development of the tissues. Space precludes me from entering into any 
detailed explanation of development, so far as it regards this subject; but I 
shall briefly state the principal results of my researches. 

" All the tissues of the organism form two grand series ; the one composed of 
cells and scales [ou lamelles), the other of fibres ; and this essential distinction 
characterizes the different elements from their very first appearance. Nuclei 
placed in a soft amorphous substance, become surrounded, in the first instance, 
by membranes ; they increase in size, multiply, and constitute the cells, of which 
the glandular, epithelial, and other tissues are composed. In the second class, 
on the other hand, the nuclei are placed in an amorphous, homogeneous, solid 
substance, which splits, and goes on subdividing into more and more delicate 
fibres, so as eventually to constitute a fibrillated tissue. There is no cell-form- 
ation in all this series of organic elements, among which may be classed the 
fibrous, cellular, and serous tissues, etc. 

" This principle of development and of texture, inherent in each series of the 
tissues, is rigorously maintained in all their various physiological and pathologi- 
cal phases. In the normal renovation which accompanies secretion, growth, etc., 
as well as in anomalous renovation or in regeneration, we always observe that 
cells are developed in those places where cells originally existed, and that 
fibres are developed in the other tissues. Although hypertrophy may occur, 
the same principle continues to preside over the production of the new ele- 
ments ; fibres do not produce cells, nor cells fibres, but cells are always de- 
veloped in the midst of cells, and fibres in the midst of fibres. 

" Facts have proved to me that these principles hold good in the case of 
cancer. The cancerous diathesis may affect the blastema, which ought to pro- 
duce either cells in the glands, scales in the epithelial, or fibres in the fibrous 
tissues; and according to the nature of the tissue infected by the diathesis, 
the morbid blastema will produce either cells or fibres. The product will 
then be characterized according to the species of the affected blastema : and 
we will have either cancer [cancer d cellules), fibro-plastic tumours (cancer d 
fibres), or cancroid growths [cancer d lamelles). But if it be permitted to us in 
most, though not in all cases, to recognize the alteration produced by the dia- 
thesis in the cells— that is to say, if we are allowed to recognize the cancerous 



214 



Progress of the 3Iedical Sciences. 



[July 



cells, and to distinguish them from other analogous elements — why may we 
not also take into account fcbres and scales as elements of cancerous tumours ? 
So long as we are unaware in what respect fibres and scales are altered when, 
they are produced under the influence of the cancerous diathesis, so long will 
the microscope continue to give imperfect information to the surgeon in the 
diagnosis of tumours. 

" As to the frequency and gravity of recurrences, all histologists know that 
there is no element which is increased, developed, multiplied, and regenerated 
with so much facility and rapidity as the cell. Fibres are much more tardy 
in the stages of their development. Now, in which of the varieties of cancer 
are the recurrences the most frequent and the most serious? Which species 
extends most rapidly, invades neighbouring organs most speedily, and destroys 
most energetically the whole economy? Undoubtedly, it is the cancer with 
cells [cancer d cellules.) The conditions are completely changed when the can- 
cerous diathesis affects a blastema which ought to produce fibres ; and when we 
see it form incompletely developed fibres, we call it the Jihro-plastic element. 
Fibres, in general, are developed very slowly. I have seen a regenerated ten- 
don presenting incomplete fibres at the end of seven years ; that is to say, 
there was a blastema in which fibrillar division had not been completed. Thus 
the microscope is capable of informing the practitioner of the severity of the 
afiection, and it also enables him to pronounce a proper prognosis as to its 
course, and as to the greater or less probability of its recurrence, inasmuch as 
it acquaints him exactly with the nature of the elements which constitute the 
tumour. 

"I believe, then, that cancer, capable of occasioning general infection, can 
exist without the cancerous cell — that heteromorphous element which has 
been considered to be a peculiar and specific product of the diathesis — being 
present. This belief of mine has been long ago expressed by M. Yelpeau, as 
well as by Bennett, Paget, Yirchow, Yogel, and others. 

"The cancerous diathesis may affect cells, scales [lamelles], and fibres, and 
accordingly there are as many difi'erent varieties, yet microscopical anatomy 
agrees with clinical observation in classing them together as one family. 

M. Amussat felt confident that he had cured many very serious cases of cancer, 
which otherwise must have terminated in a painful and horrible death. The 
influence of grief appeared to him to be, speaking generally, the most frequent 
cause of cancer in persons of otherwise good constitution ; hence he was led to 
believe that the seat of cancer lay in the nervous system. He trusted that 
this discussion on the microscopical characters of cancer would elicit fresh 
researches, which might elucidate the nature of the disease, and lay the foun- 
dation for a rational, efiicacious treatment of it. He thought the question of 
the greatest moment in relation to cancer was, whether or not there existed 
any hereditary taint. If this was present, the most prompt and energetic mea- 
sures were necessary. When it was resolved to operate, either by means of 
the knife or caustic, we should freely destroy the surrounding tissues, as the 
timidity of the operator often occasioned recurrences. When caustics are pre- 
ferred to the knife, only the strongest should be used. 

M. Cloquet. Cancer was like inflammation — there were many very different 
varieties of it ; yet all its various forms possessed certain common characters ; 
they never healed spontaneously ; they were very prone to recur, and, unless 
extirpated, they infallibly occasioned death. He considered that the micro- 
scopists had not formed a separate school of their own; they belonged to the 
anatomico-pathological school, and, being possessed of more powerful means 
of investigation, they had arrived at most important results. To insure our 
obtaining still more certain and important results, it was necessary that ail 
medical men should unite in strengthening the hands of the microscopists, and 
in placing within their reach everything which they considered likely to ad- 
vance the interests of science. 

M. Delafond proposed to examine the question of cancer in relation to com- 
parative pathology, to surgery, and to micrography. 

It had been alleged by M. Leblanc that herbivorous animals were less afi"ected 



1855.] 



Surgery. 



215 



by cancer than carniYorous ; but this proposition Tvas too wide ; and he believed 
that the herbivora were equally subject to its ravages. It was by no means rare 
to find cancer afi'ecting the teats of mares and the testicles of horses, and it often 
occurred in the viscera of these animals. Asses and mules were very subject 
to it. Cancer was common among oxen, especially afi'ecting the jaw. Pigs 
were very liable to cancer of the teats, and dogs were often afi"ected by this 
disease. It also occurred among gallinaceous fowls, and many varieties of birds. 
Therefore, it did not appear that animals deriving their sustenance from the 
vegetable were less disposed to cancer than those whose nourishment was drawn 
from the animal kingdom. 

He had found, from microscopical investigations, that fibro-plastic tissue re- 
curred like cancer. He did not consider the cell characteristic of cancer. The 
cancer-cell varied in its appearance according to the stage of the malady. At 
first, the cells found in a small tumour, not compressed by the surrounding 
tissues, were of a rounded form, having a nuclei and nucleoli in their centres. 
Compression subsequently rendered them elongated and ovoid ; subsequently, 
they became still more elongated ; and, in scirrhous cancers, compression de- 
formed them still further. In old cancers, they become infiltrated with cal- 
careous matters : their nuclei become flattened, and the cells become thin, like 
fibro-plastic tissue. Secondary cells also become developed within the parent 
cells, both being inclosed within a common membrane. In encephaloma, where 
there existed abundance of liquids and fatty matters, the cells were rounded 
or ovular. 

He had read that a German pathologist had been able to produce cancer by 
injecting the juice of a cancerous tumour into the veins of a healthy dog. He 
had several times tried this, but had never been able to obtain any such suc- 
cessful results, although he had injected cancerous juice containing abundance 
of cells into the veins, and had put it into the trachea, and had also inserted it 
beneath the integuments of animals. The characteristic element of cancer 
was not the cell, hnt the Juice in which it floated. Inoculation with the pus 
of glanders produced glanders ; that of the varioloid disease of sheep gave rise 
to the same disease ; and the saliva of the hydrophobic dog occasioned canine 
rabies ; yet the pus and the saliva in these diseases presented no special cha- 
racters when microscopically examined. Thus there existed different properties 
with identical appearances. 

As regarded the dimensions of the cells, he considered that the cells of fibro- 
plastic tissue were the smallest ; those of encephaloma the largest ; whilst those 
of scirrhus were of a medium size, between that of the other two. The appear- 
ance of the nuclei and nucleoli varied very much, according to the variety of 
cancer examined ; they were very small in fibro-plastic growths. These facts 
accorded well with clinical results ; for it was known that encephaloid tumours 
grew more rapidly, spread more certainly, and produced general infection more 
speedily than any other variety of cancer. 

He described the efi'ects of various reagents on the cancer-cell, and showed 
the importance of acetic acid in rendering more distinct the nucleus and nu- 
cleolus. 

He eloquently defended the use of the microscope, and maintained that it 
had great claims to the attention of all practical men, because if by means of 
it they perceived the cells which ordinarily accompanied cancer, their diagnosis 
became more certain, and they knew that they had to deal with either fibro- 
plastic, scirrhous, or encephaloid tissue. 

As regarded tJie treatment of cancer, he recommended early extirpation. He 
had found that, after the removal of a cancer, there were a great many of the 
— he would not say characteristic, but habitual cells of cancer, disseminated 
tiirough all the normal tissues near the spot aflected, and also through those 
which were at some distance from it. Hence, in excising cancers, we ought to 
cut away a considerable portion of the surrounding tissues, even though they 
appeared healthy and unchanged, and that we ought even to cauterize them after- 
wards. By microscopically examining the discharges from wounds left by ope- 
rations for the excision of cancer, he had ascertained that, so long as the 
pus contained cancer-cells mixed with the pus-cells, cicatrization did not 



I 



216 Progress of the Medical Sciences 

take place ; and that, simultaneously with the disappearance of the cancer- 
cells, the process of reunion commenced. lie was, therefore, of opinion that, 
after removing a cancer, we should allow the wound to suppurate for a certain 
time, in order to allow the cancer-cells to be eliminated by this channel. — 
Monthly Journ. Med. ScL, Jan. 1855. 

39. On the Formation and Extension of Cancer- Cells in the Neighbourhood o f 
Cancer, and their Importance in the Performance of an Opei-ation. — The fol- 
lowing are the conclusions of Schroeder Van Der Kolk : — 

1. Through an interchange of material, taking place between cancer-cells and 
intercellular fluid, the latter acquires the property of forming new nuclei and 
cells of a similar nature. 

2. This intercellular fluid passes, along with the parenchymatous fluid per- 
vading the sound parts, into the textures adjoining the tumour. The paren- 
chymatous fluid thus acquires the same constituents and tendency to form 
similar cells, which now become developed among the healthy surrounding tis- 
sue, in the course of the areolar membrane. 

3. On account of the minuteness and small number of the last-mentioned 
cells, their presence cannot be detected with the naked eye; so that the sur- 
rounding parts may appear to be perfectly sound, notwithstanding that they 
contain the germs of the advancing formation of cancer. 

4. It is, therefore, of importance, in removing cancer by operation, not only 
to take away, at the same time, a large quantity of the adjacent sound parts, 
but also to examine the innermost sectional edges under the microscope, in 
order to ascertain whether any trace of cancer-cells in process of formation is 
to be discovered in them. 

5. The existence of burning, shooting pains in carcinoma, may be taken as 
a proof that the cancer-cells have reached the neighbouring nerves, and the 
disease can then scarcely be looked upon as a local one, in which an operation 
might be permanently successful. 

6. By the absorption of the infected parenchymatous fluid through the lym- 
phatics and veins, the whole body seems to become more or less tainted, so that 
secondary cancer ensues in distant situations, when, as is self-evident, operation 
.can no longer be thought of. 

7. This altered parenchymatous fluid penetrates the organic tissues, which 
are washed by it, the sarcolemma of the muscular fibres, the tubes of the nerves, 
&c. These membranes, too, both the sarcolemma and the walls of the nervous 
tubes, appear to take up the altered nutritive fluid; the consequence of which 
is, that both within the sarcolemma and the nervous tubes similar nuclei and 
cells arise, accompanied with an absorption of the muscular fibre and of the 
contents of the nerve, and attended with the deposition of fat, by which these 
parts waste and are destroyed, while the surrounding membranes (sarcolemma 
and walls of the nervous tubes) remain. — Brit, and For. Med.-Chirurg. Rev., 
April, 1855, from Lederlansch Lancet, Sept. 1853. 

40. Cancer with Benign Clinical Features. — Dr. Robert D. Lyons, in a paper 
recently read before the Dublin Pathological Society, states that he has on 
several occasions seen examples of undoubted cancer, which wanted many of 
the so-called malignant features ; and he relates the following case as the most 
remarkable one of the kind, in many respects, which he has met with. 

" The patient was aged 37. At the time I saw him, the disease had been in 
progress somewhat more than a year. He had enjoyed excellent health, and 
was not aware of the existence of any disease, until, having been tripped one 
day in the street by a dog, he shortly afterwards noticed a small tumour on the 
inside of the left groin, which subsequently increased in size, but gave him 
little pain. Indeed, with the exception of the inconvenience caused by its 
gradually enlarging dimensions, he had no cause of complaint whatever. 
Advice, however, was sought, and the question of the propriety of operation 
was entertained ; but a second opinion having been taken, it was finally de- 
termined to allow matters to follow their own course. 

At a subsequent period, I saw the case, when the following observations 



[July 



1855.] 



Surgery. 



217 



were made, which I transcribe from my note-book : The patient was pale, sal- 
low, and emaciated. The tumour had steadily increased in size, until, when 
measured over its greatest prominence, the limb was found to be two feet one 
inch in circumference, the opposite one in a corresponding situation being but 
17J inches. The tumour occupied the inner and anterior parts of the upper 
two-thirds of the left thigh, was of a uniform oval shape, its elevation from the 
surrounding parts being gradual and regular. It was excessively hard, but 
entirely free from pain, and could be manipulated and examined most minutely 
through its whole extent without producing the least suffering. The skin 
covering it was smooth, a little shiny, quite devoid of any irritation, and colour- 
less, except where a few small veins coursed through it. The femoral artery 
crossed the tumour on the outer side, and could be felt with ease. A small 
circular, movable, painless tumour existed above the crest of the right ilium, 
and was apparently confined to the integuments. 

" Casting the eye on the trunk, as the patient lay uncovered, it was mani- 
festly unsymmetrical ; there was an extensive uniform and regular enlarge- 
ment of the left side, occupying the left infra-mammary region, encroaching a 
little on the epigastrium, and extending through the left hypochondriac region 
to the back; it also passed downwards towards the ilium. On manual exami- 
nation and percussion, it was found that one or more solid tumours existed in 
these situations. He said that he some days previously experienced uneasiness 
in the epigastrium, but it was only temporary ; his chief suffering was alto- 
gether from flatulence : the urine, from time to time, presented a good deal of 
purpuric deposit. The chest was generally resonant, the respiratory move- 
ments tranquil, the heart's action normal ; pulse 100. These points will be 
found worthy of note. 

" I experienced considerable difficulty in arriving at a satisfactory conclusion 
as to the nature of these tumours. The absence of pain, of any tendency to 
ulceration, the patient's indifference to any kind of manipulation, the normal 
condition of all the vital organs, the freedom from local or general suffering, 
the entire absence of any of the so-called malignant characters— for throughout 
the clinical features of the disease were as benign as those of any form of 
tumour that I am acquainted with — made it a matter of great difficulty to pro- 
nounce a positive diagnosis. If the tumour had been confined to the limb, I 
should probably have fixed on the idea of enchondroma ; if to the abdomen, on 
some form of the simple fibrous or lipomatous tumours which we know are 
capable of reaching a vast size. But this is not the place to discuss all the 
bearings of the question of diagnosis in such a case. 

" The progress of the disease from this period was steady, and unmarked by 
any incidents worth noting till towards its close. 

" The tumour in the thigh gradually but sensibly increased in size : the en- 
largement of the abdomen went on from day to day, and the tumour or tumours 
— for it was yet impossible to decide whether there were more than one or not 
— began to cause some uneasiness, merely, however, from their size, and from 
their consequent mechanical interference with the organs around them. The 
colon could be traced nearly through its entire course, but, especially in the 
transverse portion of its arch, thrust forward before the mass, and often thus 
imprisoned between the latter and the wall of the abdomen. Constipation and 
flatulence now caused more suffering than the patient had at any time before 
experienced. 

"His appetite continued pretty good, but he was much emaciated, for the 
whole vegetative force of his system appeared devoted to the supply of these 
immense growths. The abdomen at length became so large as to render the 
poor patient quite unwieldly to himself, and he lay on his back unable to turn, 
and hardly able to move. 

" A little dyspnoea had been complained of from time to time, but with relief 
of the abdominal flatulence this generally disappeared too. Of late, however, 
it became increased, and was pretty constant. On one occasion a paroxysm of 
dyspnoea came on, and after a couple of days of rather severe distress of breath- 
ing, with symptoms referable to the left lung, I contrived to effect an examina- 
tion of the left side of the thorax on the lateral and posterior aspects, a thing 



218 



Progress of the Medical Sciences. 



[July 



by no means easy of accomplishment, as it was almost iaipossible for him to 
sit up. Dulness on percussion was found as high as the infra-scapular region 
behind and the fifth rib in front. Coupling this with the paroxysm of dyspnoea, 
cough, and other symptoms referable to the left lung, and as I had now for 
some time regarded the case as one of cancer, I concluded that cancerous de- 
posit had taken place into the left lung. How far this conclusion, from such 
symptoms and signs, was warranted may, perhaps, be questioned now ; but it 
also admits of doubt, whether we have arrived at any principles of physical 
diagnosis capable of deciding what the actual state of parts is under similar 
conditions, I may here first briefly state that, in the case in question, it was 
not what I supposed. As will be seen in the sequel, cancer had been deposited 
within the thorax, but not in the organ, nor in the manner in which I was led 
to believe. 

" It will be unnecessary to follow the case in further detail ; suffice it to say 
that the disease progressed steadily, and the tumours continued to enlarge 
gradually but sensibly. To the end the only suffering was from flatulence, 
the sense of tension and distension in the abdomen, and occasional dyspnoea. 

"In about a year and a half from the first date of the disease, or rather, to 
speak more accurately, from the period at which the small tumour in the groin 
was first noticed, he died somewhat suddenly. 

" I examined the body with much interest and attention. 

" The tumour in the left thigh was found to be one uniform mass, of oval 
figure, smooth on the surface, entirely unbroken, free from any connection 
whatever with surrounding parts, and easily detached from them ; it had 
passed in deep, so as to reach the neck and shaft of the femur, but there was 
no mark or erosion of any kind on the bone, which in all respects appeared 
perfectly healthy, and the growth but lay in contact with it. 

" On opening the abdomen, a tumour of enormous dimensions came into 
view, partly obscured by the colon which ran in front of it and was attached to 
it ; the lower part of the peritoneal cavity was filled with extravasated blood. 
The tumour was found to be one continuous solid mass, reaching from the 
diaphragm to the groin, moulded on the spine, but free from it, as it appeared 
to be from everything with which it lay in contact, as the intestines, the liver, 
the spleen, and above all, the left kidney, which was inclosed in a kind of cleft 
in the tumour, and flattened out to the shape and dimensions of a hand, but in 
all respects healthy, and its peritoneal covering uninjured. 

" I examined with care for the source of the effused blood, and can only 
suppose the hemorrhage to have taken place in the following way, by rupture 
of veins, and this I believe to have been the immediate cause of death. 

" The colon, as I have stated, lay in front of the tumour, so did the omentum 
and part of the meso-colon, both of which were thus compressed between the 
tumour and the wall of the abdomen, and in consequence their numerous ves- 
sels had undergone distension to an enormous degree, and when this distension 
was carried beyond a certain point the veins had given way, had poured their 
blood into the peritoneal cavit}?-, and had thus caused death, for the quantity of 
blood eS'used was very considerable. 

"I directed particular attention to this great tumour, with a view to deter- 
mine, if possible, from what point it had sprung ; but this I was quite unable 
to do ; it was connected only with the mesentery, for though it touched almost 
•every part and organ within the abdomen, it had no connection with any of 
them. There was no disease of the lumbar glands, no deposit in the liver, 
spleen, or kidneys, and all these organs were in a perfectly healthy condition. 

" On opening the thorax, the lungs were found quite healthy ; no inflamma- 
tion, congestion, or deposit of any kind existed in them. The left pleural 
cavity was, however, greatly diminished in size in the vertical direction, the 
left ala of the diaphragm being thrust up before an immense lobe of the great 
abdominal tumour, so as to be on a level with about the fifth or sixth rib. This 
enlargement had probably taken place in this direction with some rapidity; 
hence the sudden paroxysms of dyspnoea, and hence, also, the absolute dulness 
and absence of respiration at the infra-scapular region, and up to the fifth rib 
in front. 



1855.] 



Surgery. 



219 



" And here I may call attention to what I conceive constitutes an unsolved 
problem in physical diagnosis. Given, diilness and absence of respiration on 
either side of the chest, with an immovable diaphragm fiom whatever cause, 
enlarged liver or spleen, or tumour such as that now under consideration : re- 
quired, to determine the condition of the intra-thoracic organs. 

"But I have said that there was a cancerous deposit within the thorax. 
Though not into the lung, a deposit had taken place into the heart ; a mass of 
a square form, and about two inches in diameter, was impacted in the wall of 
the left ventricle, projecting into the pericardial sac : but however long or 
short a time it had existed in this situation, I never had the least suspicion of 
such a deposit, nor was there in the action of the organ any one abnormal con- 
dition to draw attention to it, though I had repeatedly examined it with care. 

" On section, these several tumours presented as beautiful an appearance as 
I have ever met with in dissection of such structures. The surface of section 
■was of a rich cream colour, lightly tinted with the delicate lemon yellow one 
often sees in cancer, the whole looking like the section of some rich, ripe fruit. 
The substance was pretty firm and homogeneous throughout, and these appear- 
ances were almost identical in all the specimens. The histological elements 
were, I may briefly say, those of cancer, exhibiting cells, nuclei, and other ele- 
ments agreeing with those of cancer in all respects. That this remarkable 
disease was cancer no doubt remains on my mind, though to prove to an abso- 
lute demonstration that it was such is, I believe, hardly possible, except to 
those who admit the existence of special histological elements. 

"If we take a survey of the chief features of its clinical and anatomico- 
pathological details, we shall find that it wants several of the characters 
assigned to what we may term the normal type of cancer, or cancer selon les 
regies. 

" At no one period did it present a single symptom or character which could 
be called malignant. 

" Confining ourselves to its clinical history, its course was undoubtedly 
BENIGN, for it did not ulcerate, it caused no pain, it simply grew with a vege- 
tative force. 

" Taking the phenomena presented during life at any given time, they could 
be readily explained by supposing, for example, that the tumour in the thigh 
was an enchondroma, and that in the abdomen some accidentally co-existent 
indiflerent growth, a fibrous one, for instance. Other equally obvious explana- 
tions will occur to your mind. 

"Looking to its pathological results, we find these also very singular: it 
attacked no neighbouring structures ; it lay on a bone, and did not erode it ; it 
inclosed, compressed, and flattened out a glandular organ, such as the kidney, 
and yet in no way invaded its structure. I know not how to trace any ana- 
tomical or physiologico-pathological connection between the seats of the pri- 
mary and secondary growths ; in what relation the groin, the mesentery, and 
the left ventricle of the heart stand to each other, I am at a loss to conceive. 
The ordinary channels of communication, the bloodvessels, or the lymphatics, 
could not have been the medium of transit of the germs of the disease ; neither 
the lumbar glands, nor the liver, nor the lungs, which are so often the points 
of arrest, were here in the least degree affected ; there was not, then, in this 
case, secondary infection or deposit in distant organs, that great criterion of 
cancer diagnosis in the ordinary sense. This, usually regarded as perhaps the 
most highly malignant and fatal feature in true cancer, was wanted in the 
case before us. 

" From the absence, then, of the various characters usually denominated 
malignant, and from a consideration of the mild clinical features presented by 
the case through its whole course, I have used what may seem a bold, if no't 
unwarrantably hazardous figure, and called it an example of Benign Cancer ; 
malignant it was not, in any sense of that ill-used word; it was fully as inno- 
cent or benign as any of the tumours known as such, and I have taken advan- 
tage of these facts to associate the term Benign with that of Cancer. This I 
have done advisedly, and not without a purpose. I believe that the slovenly 
language which is so often used to cloak ignorance or imperfect diagnosis, ancl 



220 



Progress of the Medical Sciences. 



[July 



for this purpose employs the word malignant to tie together seToral diseases 
essentially different, betokens a slovenly pathology worse than uselsss, for it is 
an immediate impediment to the advancement of our science. I have contended 
> against it, and I hope to see it soon exploded. 

" It is often asked me, when a specimen of disease is put into my hands for 
examination, whether it is ' malignant' or not, to which I always reply, * That 
is a question to be answered by the clinical history of the disease, but it is en- 
tirely outside the province of pathological anatomy.-' A disease may be highly 
malignant, like the eroding cutaneous ulcer or the squirre en cuirasse, and yet 
not be cancerous ; and I believe a growth may be found to be Cancer histologi- 
cally, and yet to have exhibited a comparatively Benign course in all its clini- 
cal features. 

" The diagnosis of the so-called malignant diseases has been cast as an 
opprobrium against the faces of the rising school of scientific pathologists, be- 
cause they cannot reduce an equation essentially complex in its nature and the 
number of its terms, to a popular expression intelligible to those who will not 
go deeper than the a 6 c of oar science. With the words benign cancer, to 
use a term warranted by the days in which we write, I throw a shell into the 
opposite camp, the explosion of which will, I trust, help to carry away the 
mists of doubt, error, and unscientific pathology which crowd round the word 
malignant.-'' — Dublin Hospital Gazette, April 15, 1855. 

41. Hi/sterical Affections of ilie Joints. — F. C. Skey, Esq., in a clinical lecture 
delivered at St. Bartholomew's Hospital (Jan. 19, 1855), made the following 
remarks on these interesting affections, to which attention was first drawn 
about 20 years since by Sir B. C. Brodie. 

" You will see abundance of hysteric hip affections, and in yet more abun- 
dance, hysteric affections of the knee. So general are these forms of disease, 
that I declare I think less error would result if every example of disease of 
these two joints, not caused by accident, which occurs in young women between 
sixteen and thirty years of age, were treated as hysteria. I state this opinion 
with the less hesitation, because -^^e rarely have much difficulty in detecting 
the real disease. We can distinguish the real from the spurious much more 
readily than we can detect the spurious from the real. An hysteric affection 
of a joint is marked, first, by the sex and age of the person — generally a female, 
and young; second, we have more pain than in real disease ; the pain is ir- 
regular — sometimes severe, sometimes entirely absent. On examination, the 
approach of the hand to the neighbourhood of the joint is attended by an excla- 
mation anticipatory of pain, and a shrinking from pressure, often with tears. 
Pain is expressed on slight, but not increased by heavy, pressure, and rough 
manipulation. You may boldly shake the entire limb while the patient's 
attention is engaged in some collateral thoughts. The head of the femur may 
be boldly revolved in its socket, and the limb carried round in all directions, 
at first slowly, and then with gradually increasing force. 

"I saw a lady, some months since, of about thirty-five years of age, who was 
brought up to London for surgical advice, on account of a severe affection of 
the hip-joint which she had suffered from for some two or three years. She 
was on the point of leaving town Avhen I paid her a single visit. When I 
entered the sitting-room of her lodgings, she was lying on the sofa. I requested 
. her removal to a bed in the room adjoining. While being carried to bed, her 
cries were most distressing, and some few minutes elapsed before I was admit- 
ted. When I again saw her, she said she really feared she could not submit to 
be examined ; but I tranquillized her by speaking kindly and gently, and she 
at length submitted. I watched her face while I extended my hand towards 
her joint, and I never saw suffering more clearly depicted. I laid my hand 
with the utmost gentleness on her trochanter, and very gradually pressed it 
against the bone, and she did not shrink. Distracting her attention to the 
early history of her case, I quite raised her thigh, and turned it first gently, 
and then with force, though slightly, in all directions, and I then struck my 
hand repeatedly, and with force, on the trochanter. Everybody round the bed 
appeared astonished; and well they might be; for such force, applied to a 



1855.] 



Surgery. 



221 



joint that had been kept absolutely motionless for months, Tvhich appeared 
permanently inverted, and apparently abridged of its length, by reason of the 
curvature of the lumbar vertebrae, with a limb much wasted by inaction, might 
be deemed a curious expose of its past history. This lady^s health was wasted 
by long confinement and severe local and general depletive treatment. Of the 
result 1 know nothing, though I had one letter from the family, stating her im- 
provement. I should mention, that the especial reason which led to my opinion 
being taken on this lady's case was to ascertain whether or not her femur was 
dislocated, and the question was not, judging from the appearance of the limb, 
an inappropriate one. The thigh was drawn up, considerably inverted, and 
apparently fixed. All the tissues were soft and flabby, and the limb extremely 
pale. Any attempt to move it with the consent of the patient was followed by 
acute suffering. On examination, the anterior spine of the ilium was drawn up 
by long-continued curvature of the lumbar vertebrse, but the length of the 
entire limb was unchanged. 

" The difficulty of these cases is greatly increased by the local appearance of 
disease. In hip cases, the position of the thigh is distorted — more or less 
fixed ; and the whole limb is inverted. In the knee examples, the joint is 
swollen, and often hot. It rests, however, perfectly straight in iDed. In the 
former, we can detect the absence of that form of dislocation which its condi- 
tion simulates, by the normal relation of the trochanter major to the anterior 
spinous process of the ilium. We are rendered suspicious of the existence of 
true disease by the more advanced age of the hysteric patient; by the severity, 
and, at the same time, the irregularity of the pain ; and by the constitutional 
character of the patient. In the knee cases, although the joint is swollen and 
the skin hot, yet the cavity of the joint is, for the most part, free from an un- 
due quantity of fluid ; and the swelling, as has been remarked by Sir Benja- 
min Brodie, is confined to the sides of the ligamentum patellas. We more 
generally find irregular catamenia than otherwise, although this feature is not 
invariable ; and we have an hysteric diathesis on which to base our inquiries. 

" In some cases, the harmony of the muscular action of the limb is entirely 
lost, and one set of muscles prevails in action over its antagonists. These in- 
subordinate agents are mostly those of flexion: the arm may be bent up to an 
acute angle at the elbow joint, or the fingers may be closed, or the thigh drawn 
forcibly and closely up on the pelvis, one example of which I have mentioned. 
Amputation of such limbs formerly practised left the diseased cause behind, 
but to be developed in other localities of the body. All these patients betray 
a weak condition of bodily health ; the pulse is small and quick ; the tongue 
pale-coloured ; and severe and chronic cases are generally coupled with more 
or less of emaciation and debility of frame consequent upon it. 

" When local pain is a prominent symptom, it rarely fails to succumb to the 
external application of opium, combined with a moderately stimulating lini- 
ment, such as the compound soap liniment. It is needless to apply for aid to 
any form of opiate tincture ; nothing short of the extract will suffice : and I 
commonly employ the fluid extract of opium — such as is now a good deal used 
by the druggists in the neighbourhood in which I reside, and to several of 
whom I have myself introduced it. 

" The catamenia should, of course, be encouraged, but not forced ; and, for 
general treatment, we must resort to iron, bark, good nutritious diet, with 
which a certain quantity of fermented liquor, whether beer or wine, in some 
form, should be combined. The profession is indebted to Sir Benjamin Brodie 
for an excellent practical work on this interesting subject.^' — Lancet^ February 
24, 1855. 

42. Efficacy of Opium in the Cure of Chronic Ulcers of the Leg. — Mr. F. C. 
Skey, in a clinical lecture, delivered January 12th last, at St. Bartholomew's 
Hospital, makes the following remarks on the efficacy of opium in the treatment 
of chronic ulcers of the legs: — 

"I venture to attribute to this remarkable drug (opium) the property of pro- 
moting the formation of healthy granulations on a surface that, notwithstanding 
all the previous appliances of surgery, is yet flat, pale, and ungranulating. 
No. LIX.— July 1855. 15 



/ 



222 Progress of the Medical Sciences. [July 

Now, there is no example of the power of opium to effect this object, more con- 
clusive, or in which there is more work to be done, than that form of disease 
of which I am speaking — which consists of a gap formed on the surface of the 
body, of greater or less depth and diameter, and in which there exists not even 
a trace of a curative action — and yet the object is accomplished by means of 
this agent, and often with remarkable celerity. We call opium a stimulant 
and a sedative. As a stimulant, it is not very often employed in practice ; 
while its properties, as a sedative, are well known, and are in daily requisition. 
Its property of mitigating pain and of promoting sleep, is that for which it is 
almost exclusively employed, and so completel}'' is its action associated with 
this sedative principle that its occasional influence as a stimulant is almost 
entirely lost sight of, and the stimulating property has merged in the supposed 
sedative. How otherwise can we explain the reasoning of Mr. Pott, who may 
almost be termed the father of modern British surgery. In speaking of the 
subject of opium in the treatment of gangrena senilis, he refers its undoubted 
efacacy to its property of soothing pain. He says : ' I have always found that 
whatever tended to calm, to relax, and to appease, at least retarded mischief, 
if it did no more J 

" But, in truth, pain, though common, is by no means an invariable con- 
comitant of senile gangrene : and it is tolerably notorious that opium is a valu- 
able remedy in all cases of this disease. How, then, on what principle, does 
opium act in those numerous cases of senile gangrene that are destitute of 
pain, and in which it is an equally efficacious remedy? 

" I believe that its sedative properties have little concern with the result. In 
truth, opium is a most valuable stimulant of the vital powers, and whether its 
action originate with the centre or the periphery of the circulation, whether 
primarily on the heart or on the capillary vessels, I do not pretend to know ; 
iDut there is no drug, simple or composite, known to our pharmacologists that 
possesses an equal power with opium, of giving energy to the capillary system 
of arteries, of promoting animal warmth, and thus maintaining an equable 
balance of the circulation throughout the body. To maintain the balance of 
the circulation ! How much of meaning is attached to these words ! How 
many affections of the bodily frame may not be brought within the range of 
this definition ! Take the common chilblain ; what is it but a local congestion, 
of blood caused by defective capillary power ? — there is no better remedy than 
opium; cold feet, as characterizing a person or a constitution, equally relieved; 
senile gangrene, the result of arrest of the capillary circulation, or its apparent 
opposite, local hypersemia — these diseases, one and all, manifest a loss of local 
power, a failure in the balance of the circulation. The term 'inflammation/ a 
word formerly in the mouths of our professional brethren on all occasions, is 
now limited in its application, and should be yet more limited, and I believe, 
in a yet more advanced state of medical science, will be restricted to an actually 
rare condition of the system. The influence of opium in such conditions is 
that of promoting a genial warmth over the system, a glow exactly resembling, 
and in fact identical with, that produced by the reaction on the system which 
is caused by the cold bath. It is local health, and the sensation is most agree- 
able. The benefit derived from opium, when administered for the purpose of 
arresting inflammatory action of the vessels, admits, I think, of much doubt, 
and should be resorted to with some hesitation as a remedial agent, though I 
am quite persuaded that the evil of its administration is greatly overrated. 
But who will profess ignorance, in these days, of the inestimable value of this 
agent when resorted to immediately after an attack of inflammation has been 
subdued by a local or general bleeding? Here we can imagine that, the acti- 
vity of the disease being checked, the diffusing influence of opium on the circu- 
lation may act as a simple derivative, operating on the vessels at the moment 
they are not indisposed to yield up their blood, and to which indeed they are 
compelled by the diffusive power of the general stimulus. 

" Many years ago, and before the introduction of railway travelling, I was 
summoned late one afternoon to see a patient some eighty miles from London. 
I travelled outside the mail. This occurred in the month of December, and the 
night was extremely cold. By some mistake I omitted to bring my great-coat; 



1855.] 



Surgery. 



223 



and, for the first hour, I suffered a good deal. On reaching a town at some ten 
miles distance from London, I took the opportunity, while changing horses, to 
run across the street to a druggist's shop, where I ordered a draught, containing 
twenty-five drops of tincture of opium. I believe I was the only person outside 
the coach that night who did not suffer the slightest sensation from cold. But 
it will be urged by many, who have experimented on, and who have observed 
less than I have done, the medical properties of opium, the infinite importance 
of studying the reactive effects of this deadly poison, and they would inquire 
into the condition of a person so treated on the following day. You may be 
assured that it amounts to nil. You will, I am sure, readily understand what 
I mean when I say the cold and the opium mutually balanced and mutually 
neutralized each other. There could be no reaction, because the influence of 
the depressing agent, viz : the cold, rather than otherwise, exceeded in duration 
that of the stimulant. If the period of prostration were brief, and limited to 
one or two hours, the argument might hold; but it is but a sorry objection to 
be urged after all. 

"I wish I could impress on the minds of the medical authorities in the Cri- 
mea the real benefit that might be derived to our noble troops, beaten down by 
intense cold and suffering in its various forms, from the judicious administra- 
tion of opium. If twenty-five or thirty drops of tincture of opium, in addition 
to his ordinary quantum of rum, were administered to each soldier whose 
nightly services are required in the trenches or on guard, you would hear little 
complaint of cold for that night, neither would it produce the smallest tendency 
to sleep. And what do you imagine would be the objection urged against the 
proposition? ' You would destroy the efficiency of the entire army; you would 
corrupt their morals ; you would engender the most enervating habits : they 
would all degenerate into professed opium-eaters ; and, in fact,^ say the alarm.- 
ists, 'the idea is preposterous.^ Here, again, I assert that no possible evil 
could result ; the only sensation, present and future, would be the absence of 
cold. If cold beget suffering, opium is the antidote to that suffering, and the 
one will assuredly neutralize the other. 

"Notwithstanding the prejudices and the bigotry that have long beset the 
public mind on this subject, and from which our profession is not totally ex- 
empt, there is no comparison to be drawn between the practice of dram-drink- 
ing and the excessive indulgence in the use of opium. The man who indulges 
in spirituous liquors makes daily inroads on his digestive powers not less than 
on his brain. His appetite is destroyed, and the pabulum for his blood is with- 
held from his circulation. He is stamped for life, and his perfect health is 
irrecoverable. The influence of opium, when taken as a means of indulgence 
though deleterious, is not permanently injurious. It exercises no serious influ- 
ence on his digestion or on his cerebral organs, and, the practice once control- 
led, leaves him in a condition to regain, without difficulty, the fullest vigour of 
both bodily and mental health. 

" I have related to you the particulars of several cases of chronic ulcer in 
which recovery was attributable to the medical properties of opium, and almost 
to opium alone. The character of these ulcers strongly marks the inactivity of 
their nature, and hence the class of society to which they belong. They are 
marked by a flat base, which indicates, by its pale, flabby uniformity of sur- 
face, that no reparatory action has approached it. It is often surrounded by a 
thick, high ridge of lymph, covered by unhealthy integuments. The depth of 
the ulcer, which may be seven or eight lines, is caused partly by the ridge, and 
partly by the excavation of the ulcer below the natural level of the healthy 
integuments. So long as this ridge exists, although granulations may form, 
and will form, from the date of the employment of the opium, yet cicatrization 
will never complete the process of cure unless the wound or ridge be absorbed. 
Now the action of opium is not alone exhibited in the development of healthy 
granulations, but in the entire complement of such actions as are required by 
the sore, viz : the formation of new material, and the absorption of the old. 

" The influence of the stimulant is exhibited therefore not on one particular 
function. It does not merely promote secretion, but it stimulates to healthy 
vital actions in their entirety, viz : secretion, organization, and absorption con- 



224 



Progress of tlie Medical Sciences. 



[July 



temporaneously; the granulations are secreted and organized, -while the cir- 
cumvallation of unsound material, the product of years of growth, is gradually 
absorbed and reduced to the level of the surrounding integument; for the re- 
moval of this wall is quite as indispensable to the ultimate result as the oblite- 
ration of the cavity by granulation. Without the two surfaces be brought to 
the same level, the process of cicatrization, or skinning over, will never be 
perfected. 

" If, therefore, we find that a disease like that I have described, and which 
exhibits so palpably a dormant condition of the remote capillaries, is amenable 
to this form of stimulant, which can only accomplish the cure by the substitu- 
tion of healthy for morbid actions, why should we restrict its employment to 
this class of diseases ? Why, as I have elsewhere inquired, may we not experi- 
ment with success on any local disease dependent on the same cause, viz : an 
inert condition of the remote vascular system ? 

" In claiming for opium the merit of rousing into healthy action the dormant 
capillary system, to the end of accomplishing the permanent cure of the chronic 
ulcer of the legs in old persons, I by no means wish you to infer that I consider 
all other modes of treatment unworthy of trial. Indeed, I attach great value 
to that recommended by Mr. Baynton, of Bristol, and others ; but, having tested 
their value, I have no hesitation in pronouncing that which I have recom- 
mended, so far as I am competent to judge, as by far the most certain and 
efficacious." — Lancet, Feb. 3, 1855. 

43. Vapour of Iodine in Mammary Tumours. ^VL. Eichmaxn relates the fol- 
lowing case: A healthy woman, set. 47, none of whose relatives had ever had 
cancer, received a slight blow on the breast. This occasioned a hard and mo- 
bile tumour. After an absence of the catamenia for 17 months, the tumour 
became painful ; smaller glandular enlargements appeared on the breast and 
extended to the axilla; lancinating pains were felt ; the skin became adherent 
to the tumour, and the sebaceous follicles were distended with blackish matter. 
The patient refusing to submit to extirpation, M. Eichmann applied to the 
tumour a bag filled with tow, and containing also iodine, which was retained 
in situ by means of adhesive plaster. The iodine was renewed fortnightly. 
After wearing this bag for a month, the patient was greatly improved, and 
after the lapse of seventeen weeks the mammary enlargement had completely 
disappeared. — Gaz. des Hopitaux, 19th Dec. 1855. 

44. Digitalis Pommade in Hydrocele. — Last spring, an Italian surgeon named 
Bellucei published accounts of five cases of hydrocele cured by the external use 
of digitalis. Little attention was paid by surgeons to these results ; but very 
recently M. Laforgue, chief surgeon in the Hopital de la Grave, at Toulouse, 
has made trial of the new mode of treatment, and found it to be as efficacious 
as was alleged by M. Bellucei. A man, ast. 60, had a large hydrocele of the 
right testicle, and being unwilling to submit to the usual operation, besought 
M. Laforgue to try some other method. Daily friction of the tumour was 
ordered with the following ointment: R. — Pulv. folior. digitalis, 6 grammes; 
axung. 30 grammes ; misce. The patient was also ordered to wear a suspen- 
sory bandage. In a few days, the man presented himself completely cured. 
He had enjoyed excellent health during the process, and had used, in all, 18 
grammes of the powder of digitalis. — Ihid., from L' Union Med., 30th Sept. 1854. 

45. Radical Cure of Hydrocele hy Injections of Chloroform. — Prof. Laxgen"- 
BECK, of Berlin, not being satisfied with the efi'ects of tincture of iodine as an 
injection in cases of hydrocele, has recently been employing chloroform as a 
substitute for it with excellent results. He finds that it acts in the same man- 
ner as tinct. iodinei, but that it sets up adhesive inflammation more quickly 
and more surely than that remedy. After withdrawing the fluid of hydrocele, 
he injects ^i or giss of chloroform through the canula, and after allowing it to 
remain for a short time in contact with the tunica vaginalis, he allows it to 
escape, so as to avoid its absorption. The pain occasioned by it is not intense, 
even less so than that induced by iodine, and it is not of long continuance. 



\ 



1855.] Surgery. 225 

Langeabeck, in his paper, relates the particulars of four cases treated thus, in 
all of which a complete and radical cure was accomplished in from two to three 
weeks. — Dublin Hosjpital Gazette, April 1, 1855, from Deutsche Klinik, 31, 1835. 

46. Two Oases of Aneurism unsuccessfully treated hy Compression, By James 
Miller, Esq. — The author was of opinion that the question as to the treatment 
of aneurism by compression was still sub judice, and must be settled by the 
production of facts, rather than by mere reasoning. As an advocate for this 
form of treatment, however, he held it to be necessary that all facts bearing on 
the question should be adduced, and, acting on this belief, he brought forward 
these cases of failure. 

Case 1 was one which Mr. Miller had had under his own care in the Royal 
Infirmary. The patient was a shoemaker, aged 42, from Galashiels, and was 
admitted March 23, 1854. His general health was good, and the popliteal tu- 
mour was about the size of a hen-'s egg. Next day. Carte's compressor was 
applied on the femoral at its upper and lower portions. The pressure was 
moderate, and antiphlogistic regimen was enjoined. On the 27th, the upper 
compressor was removed, in consecjueuce of the complaint of pain; and on the 
5th of April it was noted that there was much pain, swelling, and oedema 
of the limb. A lump of lead, with an elastic band attached, as used in the 
Dublin hospitals, was now tried. August 1st, seventeen weeks since the com- 
mencement of the treatment, the tumour was harder and slightly diminished in 
size ; pulsation was distinct. Flannel was ordered to be applied to the lim.b. The 
lead weights had up to this time been kept constantly applied above, and Carte's 
apparatus to the lower part of the limb. Aug. 3, the patient suffered much ; 
anxious to have the artery tied. Carte's apparatus alone was now kept applied 
at night. Aug. 10, pressure was abandoned ; the tumour was harder, but still 
pulsating, becoming caudate towards its head, and increased in size towards the 
inner side. Aug. 24, five months after admission, the artery was tied. The 
parts in its neighbourhood were found more matted together than usual. At 8 
P. M. a slight thrill was perceptible in the tumour. There was sickness from 
the chloroform. Pain of the back was complained of. Aug. 25, the thrill was 
still less. Colchicum was given internally ; and chloroform was applied lo- 
cally to the back. Aug. 26, the thrill was scarcely to be felt; and on the 27tli 
it was gone. Aug. 30, the thrill had returned ; and on the 15th Sept. it was 
noted that the thrill was still present ; the ligature was yet in the wound ; it 
came away on the 18th. October 10, the tumour was at length silent, and di- 
minished ]n size. The patient was dismissed on the 14th. 

Case 2 had been under the care of Dr. Johnston, of Montrose, and was 
admitted into the Montrose Infirmary March 24, 1854. The tumour was about 
the size of a small orange, and had been first noticed in the previous July, and 
gradually increased in size. The pain, at the time of admission, was severe, the 
symptoms well marked. The health was good, and the heart sound. Low diet, 
etc., was ordered, and digitalis given internally. Carte's apparatus was applied 
at intervals, and soon another instrument alternately with it. Up to the 16th of 
August, the tumour had become flattened, and diminished in size to that of a 
walnut. The pulsation was weakened, but was still apparent. The health 
now began to flag, and on the 22d a ligature was applied. Slight pulsation was 
felt in the tumour on the 28th, but never returned. The ligature came away 
on September 14th ; and on the 15th of October the patient was dismissed from 
the hospital. Dr. Johnston attributed the successful issue to the fact of the 
pressure employed having developed the collateral circulation of the limb. 

Mr. Miller drew attention first to the fact of the pressure not having been 
easily borne. He believed that a still simpler method of applying it would 
yet be discovered. Secondly, careful watching was requisite during its appli- 
cation, as the patient, under the mistaken idea of expediting the cure, was apt 
by undue pressure to excoriate the parts and induce erysipelas. Any swelling 
of the limb, etc., demands attention, but cessation of the pressure appeared to 
suffice to dispel such dangers. Care to be taken that the pressure was not 
applied too low down. Third, it was to be noted that the collateral circula- 
tion was much affected. In the first case, the tumour first became harder, etc., 



226 



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[July 



and then pulsation appeared in it from the collateral circulation. In such cir- 
cumstances, Mr. Miller would recommend instant application of theligature, and 
if this Avas not done, difficulties were met with afterwards, even if the artery 
was tied. As it was, in this case the pulsation continued for six weeks. In 
Dr. Johnston's case, however, the collateral circulation gave no trouble after 
the deligation of the vessel. In future, if after long-continued pressure the 
collateral circulation increased greatly, Mr. Miller would cease compression, 
and, after an interval of rest, would apply a ligature, without, however, any 
risk of gangrene supervening. Fourth, as to the effect on compressed parts. 
In the first case, pain was always complained of, and a hardness could certainly 
be felt. On dissection, the parts were found much condensed, and difficulty was 
experienced in passing the needle ; but this was to be avoided by cautious dis- 
section. Fifth, after prolonged pressure, the state in which the system is, is 
one very favourable for a subsequent operation. In the first case, from acci- 
dental exposure while on the operating table, an attack of lumbago came on. 
Lastly, Mr. Miller pointed out the odd parallelism which existed between the 
two cases as to the dates of admission and of their general progress. These 
histories furnished the following arguments for and against the treatment by 
compression: Against. 1. The pressure was not well borne. 2. The effect pro- 
duced on the collateral circulation, and on the parts immediately subjected to 
the pressure, was very troublesome in the first case. 3. In both cases, the plan 
failed after a trial of five months. For. 1. If compression can be maintained 
so long, it must be a comparatively safe procedure. 2. The free collateral cir- 
culation induced was favourable to any subsequent operation, as there is less 
risk of gangrene of the limb. 3. The constitution was better prepared for the 
operation by ligature, should that become necessary. — Proceedings of 3Ied.- 
Chirurg. Sac, Edinburgh, Dec. 6, 1854, in MontMy Journ. Med. Sci., Jan. 1855. 

47. Stricture of the Urethra. 'By James Syme, Prof. Clin. Surgery. (Extracted 
from Clinical Lectures.) — I will now bring before you a case of stricture of the 

urethra of great interest. The patient, Daniel M , aged thirty-seven, a 

seaman, has long suffered severely from the disease. He was treated by dila- 
tation, eight years ago, in the hospital at Plymouth ; but, even then, small 
-instruments alone could be passed, and soon aher leaving the hospital he re- 
lapsed into his former condition. At present, micturition is very laborious 
and frequent, sometimes hourly, and the stream of urine extremely slender. 
On examination, I found a bougie of moderate size arrested, an inch and a half 
from the orifice, by an obstruction, which could not be passed by the smallest 
bougie; I then tried a common probe, but this also could not be passed. I 
now had recourse to the instrument which I hold in my hand, which was made 
for cases of this description. You see it is considerably finer than a common 
probe at its extremity, and gradually increases in thickness towards the 
handle. This instrument passed without the slightest difficulty. If the stric- 
ture had been seated at the bulb, it might have been said that the fact of my 
being able to pass only so small an instrument was no certain evidence of an 
extreme degree of contraction, as there is difficulty in guiding the instrument 
with precision at that part of the canal ; here, however, there is no such source 
of fallacy, for we can direct the instrument with certainty in the course of the 
urethra, and, small as it is, it is firm^ly grasped. The first remark I would 
make regarding this case has reference to what is called impermeability of 
strictures. Now, the No. I of our set of bougies is the smallest size that is 
made, while many sets have none so small ; so that this stricture would be im- 
permeable to all ordinary bougies. On the other hand, the very small instru- 
ment I have just shown you passed without the slightest difficulty ; and this 
case, therefore, furnishes a good example of the principle that all strictures 
that allow urine to pass out, will admit of an instrument, sufficiently small, 
being insinuated through them. The next point to which I would direct your 
attention, is the situation of this stricture, anterior to the scrotum. It is here 
that the tightest strictures have been observed to occur, which is fortunate, for 
if there should be a stricture of the same degree of tightness behind the 
gcrotum, its remedy would be attended with extreme difficulty. In the present 



1855.] 



Surgery. 



227 



case, I feel the induration of the stricture like a small pea, somewhat elon- 
gated. Now, experience shows that of all strictures of the urethra, this con- 
dition is the most unmanageable by bougies ; the patient tells us that so far 
from having experienced benefit from the introduction of instruments, his 
symptoms have rather become more aggravated, and I believe we might con- 
tinue dilatation for any length of time without advantage. Instead, therefore, 
of pursuing this unsatisfactory course, I propose to divide the stricture at once. 
But you will say, How can it be divided ? We must use a proportionately 
small director, the employment of which would be attended with great diffi- 
culty at the bulb, but will be very easy here. In this part of the canal there 
is no occasion for a long incision in the skin; the point of the knife being 
entered into the groove of the director, anterior to the stricture, will be pushed 
backwards through it, while the end of the penis is held firmly ; the same 
principle being followed in cutting backwards here, as in cutting forwards for 
a stricture at the bulb — viz., that of proceeding from the side where there is 
greatest resistance. After this, I shall pass a full-sized instrument, and I ex- 
pect it will go freely into the bladder. Of this we cannot be certain till the 
stricture at the anterior part of the canal has been divided ; but, as far as I 
remember, I never met with a tight stricture behind the scrotum along with 
an extreme degree of contraction anterior to it. There will be no need to 
retain a catheter in the bladder : the urine will flow freely, and there will be 
no risk of extravasation ; even if it did occur to the small extent which is 
alone possible, I should regard it as a favourable circumstance, on account of 
the effect it would have in preventing the urethra from uniting by first 
intention. 

[The patient was now brought into the theatre, and Mr. Syme, having shown 
that the No. 1 bougie was arrested an inch and a half from the orifice, while 
the delicate instrument above described passed the obstruction without diffi- 
culty, endeavoured to introduce a very fine grooved steel director. This, how- 
ever, could not be passed beyond a certain distance; but Mr. Syme, on feeling 
the instrument through the tissues of the penis, found that the point of the 
director had passed the stricture, which he felt like a pea upon it, and that it 
was only in consequence of the instrument being tightly grasped that it refused 
to pass further. He therefore proceeded to operate as he had proposed, after 
which he introduced successively three different sized bougies through the 
seat of stricture, and pushed on the largest (No. 8) with ease into the bladder, 
thus proving that no obstruction existed behind the one divided. Scarcely a 
drop of blood escaped during the operation. Mr Syme then made the follow- 
ing remarks: — ] 

This, then, gentlemen, is, as you have seen, a very simple process ; yet the 
patient may be almost said to be already cured. I think it likely that, instead 
of leaving the hospital very imperfectly relieved, after several months of dilata- 
tion, he will in a few days go away, without requiring any further precaution 
than the occasional introduction by himself of a steel bougie, two inches in 
length, to prevent the risk of contraction during the healing process. You 
will, I trust, not soon forget that remarkable fact which you have just wit- 
nessed — viz., that, after I had introduced the very small director fairly through 
the stricture, the firm grasp of the contracted part made it impossible to push 
it further without a degree of force, which I did not feel justified in using. 

[The operation was performed on the 15th of January. On the night after 
the operation the patient retained his urine for seven hours, and never after- 
wards voided it with unnatural frequency. It flowed in a full stream by the 
urethra, but for a few days issued also to a small extent by the wound, in the 
neighbourhood of which the cellular substance showed some signs of irritation 
by swelling and tenderness. Full-sized bougies were occasionally introduced, 
and he left the hospital to join his ship on the 6th of February. 

In his lecture on the 25th of January, Mr. Syme said : — ] 

There are two patients who have been in the hospital for the last seven 
weeks, with stricture of the urethra at the bulb, as tight as you ever meet with 
in that situation. It was at first difiicult to say which of these cases was the 
worse; both had extreme difficulty of micturition, and both incontinence of 



228 



Progress of the Medical Sciences. 



[July 



urine, and both required, in the first instance, the smallest-sized bougies, which 
I experienced some difficulty in introducing. By passing instruments regu- 
larly at intervals of three or four days I was soon able to introduce a large 
sized bougie in both cases, but neither appeared at first to improve in their 
symptoms under the dilatation. By and by, however, one of them did derive 
benefit; he lost the incontinence, and could pass his urine in a much better 
stream — in short, he is now so much improved, that I think in his case we may 
be satisfied with dilatation. You observe I express myself with some hesita- 
tion ; for the more I see of these complaints in this obstinate form, the more 
doubt I entertain as to the expediency of trusting to dilatation for their cure. 
The other patient, however, has not experienced the relief that we desired ; his 
difficulty of micturition is almost as great as ever, and his clothes are still wet 
both by day and night from incontinence of urine. I also found, after leaving 
him for a few days longer than usual without the introduction of instruments, 
that, instead of going on with the large-sized bougie I had used on the last 
occasion, I was obliged to begin again with No. 1. On my next examination 
of the urethra, ten days later, I was unable to pass even the smallest size. In 
this case, therefore, if we had no means except dilatation, we should be puzzled 
and at a loss what to do next ; but I need hardly say that we shall feel no such 
perplexity, but shall proceed to the other mode of relief for stricture — viz., 
dividing it by external incision. But before having the patient brought in, I 
will mention to you a striking case, at present under my care in private. Dur- 
ing my short residence in London, this gentleman came up from Aberdeen, and 
placed himself under my care, in order to obtain relief from a stricture, which 
had been treated for some time as impermeable by several surgeons. I at once 
succeeded in introducing a small instrument, and, after employing dilatation 
for three weeks, the urethra admitted a full-sized bougie, and he went away 
apparently well, and with the hope of continuing free from his symptoms, with 
the occasional introduction of an instrument. Instead of this, however, he has 
ever since — that is to say, for the last seven years — been perpetually under the 
care of surgeons in different parts of Great Britain. On one occasion he had 
complete retention, and several surgeons then failed to pass a catheter. But 
the remarkable circumstance is, that he has been during this period repeatedly 
treated by dilatation to the full extent. And now comes the most important 
point of all : this patient, though in full general health, not above forty years 
of age, married, and leading a regular life, and therefore not in danger of con- 
tracting the disease afresh, yet, even when the stricture was fully dilated, has 
never passed urine with ease ; he has even felt an insecurity of being able to 
void it at all, and has been frequently obliged to go out of church or to leave 
company in consequence of the importunate desire for micturition which has 
accompanied his complaint. His life has, in short, been miserable, and this, 
you observe, at times when bougies of full size could be passed into the blad- 
der. This is an example of that form of the disease which first led me to aim 
at some other means of efi'ecting that for which dilatation was evidently inade- 
quate. These cases were formerly the opprobria of surgery. It is only three 
days since I divided the stricture in this gentleman ; yet he told me yesterday 
(I have not seen him to-day) that he felt as if something was taken away that 
had made life miserable ; an incubus had been removed that had been weigh- 
ing him down during many long years of sufiering. (The relief in this case 
proved permanent.) 

[The patient was now brought into the theatre, and chloroform having been 
administered, Mr. Syme succeeded, after some little difficulty, in passing the 
thin part of his stafi" through the stricture. The rest of the operation was 
easily completed in the usual way. Mr. Syme, while he had his finger in the 
wound, observed that he could feel the artery of the bulb beating at the side, 
and remarked that this showed forcibly the danger of deviating from the mid- 
dle line in making the deep part of the incision. Mr. Syme then easily intro- 
duced into the bladder a No. 11 catheter provided with a stop-cock. The 
patient having been removed, Mr. Syme made the following remarks :— ] 

You had, not long ago, an opportunity of seeing the operation performed in 
a case complicated with fistulas, and great thickening and induration of the 



1855.] 



Surgery. 



229 



perineum; those are the cases in which the operation presents the greatest 
difficulty. Again, ten days ago, you saw me divide a stricture anterior to the 
scrotum, in which the operation presents the greatest simplicity, and is easiest 
of performance. That patient, I may remark, continues well, passing his 
urine without pain in a good stream, and the urethra admitting a full-sized 
instrument. The operation you have just seen holds a middle place as regards 
difficulty of the operation, the stricture being seated as far back as it is ever 
met with, but the perineum free from induration. You see here on the table 
the blood that was lost during the operation; though he is a young man of 
thirty, in full health, and with rather greater disposition to bleed than is usual, 
yet two teaspoonfuls would be a liberal allowance for the amount of the 
hemorrhage. 

[Everything afterwards went on favourably ; on the removal of the catheter 
at the end of forty-eight hours, the urine passed in a perfectly full stream by 
the urethra, and continued to do so, none having escaped by the wound. In a 
few days he was going about the ward, and might then have been dismissed, 
but remained under observation until the 27th of February, nearly five weeks 
after the operation, when he got his discharge after a full-sized bougie had 
been passed with perfect facility into the bladder.] — Lancet^ March 10, 1855. 

48. Notes on LitTiotrity, icith an Account of the Results of the Operation in the 
Author's Practice. — By Sir Benjamin Brodie. 

The author announced that his chief objects were — to communicate, in a 
series of notes, some observations as to those circumstances which are espe- 
cially deserving of attention, with a view to the success of the operation : to 
give a brief but accurate account of the actual results of his own practice ; and 
to add some observations as to the amount of danger involved in the operation 
by crushing, compared with that which belongs to lithotomy. He adduced 
reasons why this operation was not applicable to the period of youth, nor 
generally common or necessary in females. He preferred the forceps worked 
by a screw to that in which the force is applied by means of a rack, since the 
latter, though affording some advantages in the way of greater expedition, 
must be manifestly deficient in power as compared with the screw. The author 
remarked that no prudent surgeon would willingly undertake this operation 
unless the bladder admitted of the injection and retention of from four to six 
ounces of tepid water ; and that where this power had been lost, it had in all 
his cases but one been restored by keeping the patient in the recumbent posi- 
tion for seven or fourteen days, and injecting the bladder daily. He then 
described the steps of the operation, urging the great necessity for the gentlest 
possible manipulation of the forceps, that injury may be avoided, pain dimin- 
ished, and, by consequence, the bladder rendered less prone to contract upon 
its contents ; that, with these points in view, the forceps should never be used 
as a sound for the purpose of exploring the bladder or ascertaining the position 
of the calculus, but that the convex part of its curved extremity should be 
brought into contact with, and gently pressed against, the posterior and lower 
surface of the bladder by the elevation of its handle ; that if, when in this 
position, on the blades being separated, the stone does not fall into it by its 
own weight, the instrument may be slightly struck on one of its sides, which 
slight concussion will probably dislodge the calculus from its fixed position 
and cause it to fall; if unsuccessful in this, the forceps may be very cautiously 
turned to one side or the other, and the same rules followed in that position as 
before ; but a freer" use of the instrument should never be made, not even in 
cases of enlarged prostate gland. For such cases the author advocated the 
value of any apparatus by which the shoulders may be suddenly lowered and 
the pelvis elevated, the calculus being thus thrown into the fundus of the 
bladder. With the same object, the patient may be directed to change his 
position from side to side, or to walk about, the bladder being emptied and 
again injected. Caution was given against the use of any kind of forceps 
which retains a considerable portion of the detritus within its blades, as being 
liable to stretch and tear the urethra, induce rigors, and even infiltration of 
urine and abscess. This happened to the author in four instances, two of 



230 



Progress of the Medical Sde7ices. 



[July 



■which died. The extent to which a calculus may be crushed at any one ope- 
ration, the author stated, must depend upon the amount of inconvenience suf- 
fered by the patient, which varies materially; but, upon the whole, he thought 
it more expeditious, and generally much more safe, to be content with a mode- 
rate progress; and, with a view to form a better opinion of what the patient 
can bear without risk, he preferred not to put him under the influence of chlo- 
roform. Again, an operation too much prolonged is liable to be followed by 
rigors — an accident which is not uncommon — is a most formidable complica- 
tion, especially when combined with other disease, and against the occurrence 
of which too much care cannot be taken. The best precaution the author had 
found to be, the placing of the patient in a warmed bed immediately after the 
operation, the encouragement of perspiration by extra clothing, and the admi- 
nistration of a tumbler of wine or brandy and water. The writer had never 
found it necessary to cut down upon portions of calculus when lodged in the 
urethra ; he had always found a slight manipulation with a small gum-elastic 
catheter sufficient to change the position of the fragment and to cause its ex- 
pulsion. He cautioned members against cutting down upon the urethra in 
front of the scrotum, as he had seen it followed by troublesome abscesses from 
infiltration of urine in two instances, notwithstanding that every precaution 
was used to guard against it. Elderly persons with enlarged prostate glands, 
should be assisted in expelling the detritus by washing out the bladder daily. 
They may be directed to void their urine in a stooping or recumbent posture, 
with the face downwards. The author gave it as his opinion that the inflam- 
mation of the mucous membrane of the bladder, induced by calculus, and indi- 
cated by great irritability of the organ, and the copious secretion of mucus, 
does not form an absolute objection to the operation, although it is doubtless a 
reason for proceeding with more caution ; for, on the contrary, it often hap- 
pens under such circumstances that the crushing of the calculus is followed 
joy an alleviation of all the bad symptoms. The patient should not be dis- 
missed as cured while any symptoms of calculus remain ; a portion may be dis- 
covered after patient and repeated examinations, which, if left, would have 
formed the nucleus for the rapid formation of another stone. The author then 
referred to the difference in the density, and therefore the force required for 
the crushing of different calculi, as dependant upon their chemical composi- 
tion. In cases of copious deposit of the soft mortar-like material of phosphate 
of lime, the author had made use of a forceps, of which the fixed blade was 
made concave, so as to answer the purpose of a scoop, with great advantage. 
He had never met with a case of hemorrhage to any amount in his own prac- 
tice. He stated that, although the merits of this operation are best shown by 
cases of small calculi, when cure results after one or more crushings, yet very 
large calculi indeed, even such as have a diameter of an inch and a half, may 
be readily and safely broken up with an instrument sufficiently strong, and 
without any other inconvenience than the frequent repetition of the operation. 
The author then communicated the result of his practice in 115 cases of iitho- 
trity. In 1 case he had had occasion to perform it eight different times, in 3 
others twice, but always for fresh formations. Of these 115 cases, 9 had an 
unfavourable result; in 5 instances death resulted from the operation; in 4 
the fatal result was to be attributed to the co-existence of other disease brought 
into activity by the shock of the operation ; in 3 of the 5 fatal cases death 
resulted from the formation of urinous abscesses ; in 1 from fever and general 
constitutional irritation ; in 1 from inflammation of the mucous lining of the 
bladder and copious mucous secretion, prostrating the patient; in 3 of the 4 
fatal cases the co-existing disease was seated in the kidneys ; in 1 it was diar- 
rhoea, and not positively connected with the operation, although inserted in 
the list. The author now again urged the great necessity for gentle and care- 
ful use of the forceps in this operation, showing that many of the imperfect 
recoveries are due not so much to disease of the prostate gland, to persistence 
of the original symptoms, or to undetected fragments, as they are to rough 
manipulations and too prolonged operations on the part of the surgeon. The 
success of the operation was thus shown to have been as somewhat more than 
12| to 1 ; while from various statistics quoted by the auther, it would appear 



1855.] 



Surgery. 



231 



that, even admitting young children (so notoriously favourable for the opera- 
tion of lithotomy, the recoveries being as 14 to 1), the proportion of recoveries 
after lithotomy to deaths stands as about 5f to 1. The author concluded his 
paper by stating that his experience had certainly led him to the conclusion 
that lithotrity, if prudently and carefully performed, with a due attention to 
minute circumstances, is liable to smaller objections than almost any other of 
the capital operations of surgery, the cases to which it is not applicable being 
Yery few indeed, and chiefly those in which, from the calculus having attained 
an unusual size, the danger and difficulty of lithotomy are so great, that no 
surgeon would willingly, nor otherwise than as a matter of duty, undertake it. 

Mr. Coulson said that all must feel obliged to Sir Benjamin Brodie for hav- 
ing brought the subject of lithotrity under the consideration of the Society ; 
but there was one point on which he ventured to differ from the author, relat- 
ing to the most difficult part of the operation — viz., seizing the stone. Sir 
Benjamin Brodie had stated that the handle of the instrument should be raised, 
and the floor of the bladder depressed, so that the stone might fall into the 
hollow thus formed, and thence between the blades of the instrument. This 
was the plan generally recommended in this country for seizing the stone. 
Now he (Mr. Coulson) considered the reverse of this to be the right proceed- 
ing. The instrument should be kept as nearly as possible on a level with the 
urethra, and no hollow or depression should be made by it in the floor of the 
bladder. As soon as the instrument touched the stone, it should be placed 
lightly over it, the bladder opened, and the calculus seized. It was difficult to 
depress the floor of the bladder towards the rectum, especially when the pros- 
tate was enlarged, without pressing on the neck, and giving pain to the 
patient. And this was mentioned as having occurred in the cases related in 
the paper. He (Mr. Coulson) believed that this mode of proceeding not only 
caused pain at the time of the operation, but by producing inflammation and 
swelling of the prostate and neck of the bladder, gave rise to many of the 
serious results that followed. In cases of enlargement of the prostate, it had 
been very properly recommended in the paper to elevate the pelvis so as to 
dislodge the stone, and throw it towards the fundus. But cases occasionally 
occurred in which the stone or fragment could not be dislodged from this situa- 
tion. Kow no suggestion was made in the paper to meet this difficulty. In 
Buch a case he (Mr. Coulson) would recommend that the handle should be de- 
pressed so as to raise the instrument from the floor of the bladder, and whilst 
in this situation, it should be completely rotated, the concave part being turned 
downwards. The handle should then be raised, so that the instrument should 
incline to the floor of the bladder, and the male blade be drawn towards or as 
far as the prostate. By this manipulation, when carefully done, a fragment, 
or a stone, could be easily and safely extracted from that situation. There was 
also another point connected with the operation, on which he thought that too 
much stress could not be laid — viz : to do little or nothing more than simply 
crush the stone at the first sitting. It was desirable to let the shock of the 
first manipulation be as slight as possible, as it was impossible to foretell the 
susceptibility of the patient, and how he would bear the operation. He was 
glad to hear the use of chloroform discountenanced in lithotrity. It was abso- 
lutely necessary that the operator should know what he was doing at every 
step of the operation, and the sensations of his patient were a material guide 
for determining at least when the operation was going wrong. The important 
question, however, to solv^e, was, to what cases lithotrity is applicable ; for in 
the proper selection of the cases, the success of the operation mainly depended. 
In general terms it might be stated that when the stone was large, the bladder 
thickened, contracted, and irritable, the prostate much enlarged, and the bar- 
like ridge described by Mr. Guthrie present, and the urethra irritable and con- 
tracted, lithotrity was contra-indicated ; on the other hand, when the stone 
was of moderate size, the bladder sufficiently capacious, and not irritable, the 
prostate not much enlarged, and the urethra healthy, then lithotrity was pecu- 
liarly suitable, and might be performed with every chance of success. He 
(Mr. Coulson) said it was of the utmost importance to make a proper selection 
of cases; for even M. Civiale, with all his partiality for lithotrity, rejected out 



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of 838 calculous patients which presented themselves to him in a given period, 
290 as unfit for the operation. In properly selected cases, lithotrity might be 
considered as one of the greatest improvements in modern surgery. 

Mr. Brooke said that he had many years ago paid much attention to the 
subject, and had -watched the progress of many more cases in the hands of 
Baron Heurteloup and the late Mr. Anthony White, than had occurred in his 
own practice. He thought that the convenience of Heuxteloup's "lit rectangle" 
had not been duly appreciated by English surgeons, as it affords such an easy 
means of depressing the shoulders of the patient, or, in other words, elevating 
the pelvis, whenever any difficulty is found in seizing the stone in the hori- 
zontal position of the trunk. He protested against the method of seizing the 
stone, recommended by Mr. Coulson — namely, that of traversing the bladder, 
and even the space behind the prostate, by the open blades of the forceps, as 
being dangerous, and adhered to that mentioned by Sir Benjamin Brodie — 
namely, gently to depress the posterior branch against the posterior surface of 
the bladder, and allow the stone to fall in between the blades. He (Mr. 
Brooke) thought that the use of percussion had been too universally abandoned 
in lithotrity. A moderately soft and friable stone may probably be as well 
crushed by screw-pressure, but a large and hard stone may be comminuted by 
percussion, that would not yield to the screw. Its laminated texture is par- 
tially disintegrated by repeated slight taps with the hammer, and a few 
smarter blows will then suffice to comminute it. According to his experi- 
ments, a hard stone is broken into large fragments by the screw, but is much 
more completely comminuted by percussion. An instrument with opposed 
blades comprises a much larger portion of the stone than that in which the 
anterior blade is made to pass through the posterior ; and such may be com- 
pletely closed by gentle percussion, the intervening debris being forced out in 
the form of mud, or paste, although it cannot be closed entirely by the screw, 
and is therefore very likely to lacerate the urethra on its withdrawal, as Sir 
Benjamin Brodie had mentioned in one or two of his first cases. In regard to 
dislodging fragments impacted in the urethra, he (Mr. Brooke) was satisfied of 
the validity of Heurteloup's maxim, that fragments lodged posteriorly to the 
aperture in the triangular ligament were generally more readily replaced in 
the bladder than extracted. This might be effected by passing a moderately 
full-sized sound down to the fragment, and directing the patient to make an 
effort at micturition. At the moment when the success of the effort is evinced 
by the escape of a few drops of urine by the side of the sound, the neck of the 
bladder is relaxed, and the fragment may be readily pushed back by the sound. 
He also alluded to the utility of Heurteloup's evacuating sound in cases of en- 
larged prostate, or feeble bladder, as well as to the facility of detecting small 
fragments, even when buried between prominent rugae, by his vesical sound- 
ing-board, described some years since in the " Transactions'^ of the British 
Association. 

Mr. Charles Hawkins thought that the great value of the paper consisted in 
its having given the profession a better opportunity than they had previously 
had of judging fairly between the merits of lithotomy and lithotrity. Litho- 
trity had been regarded originally as applicable to only a very small number 
of cases ; but his (Mr. Hawkins') belief was, that it was really available in 
most of the cases in which lithotomy might be resorted to. Mr. Coulson had 
spoken of the danger which sometimes occurred from the escape of small frag- 
ments of stone from the lithotrite ; he (Mr. Hawkins) had in several such cases 
succeeded in removing these fragments by the scoop, having previously ele- 
vated the patient. He thought chloroform should never be resorted to in litho- 
trity, as it was an axiom in this operation, not to do more at one time than the 
patient could bear. Chloroform would prevent our being warned of this. In 
one case, however, he had been compelled, from the excessive irritability of 
the patient, to resort to this agent. The patient was operated upon four times, 
the bladder being materially relieved after each sitting. The case proved very 
successful. It had been said that when great irritability of the bladder ex- 
isted, lithotrity should not be resorted to ; but this could not be regarded as a 
fixed rule. In one case in which the bladder was so irritable that the patient 



1855.] 



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233 



passed water every quarter of an hour, and bloody urine followed a,ny exercise, 
he had succeeded in getting the bladder to hold' two ounces of urine, and in 
using the lithotrite twice. The case was cured ; but even in forty-eight hours 
the patient had become quite comfortable as regarded pain. With a view to 
show that the liirge size of the stone did not necessarily prohibit lithotrity, he 
exhibited the fragments of a calculus, which had been broken up after twenty 
or thirty sittings, in a gentleman, seventy-five years of age. The fragments 
weighed two ounces and a half. The patient recovered. In this case the 
s-tone would have been difficult of removal by lithotomy. His own opinion in 
regard to the operation of lithotrity was, that if the patient was not in a state 
to bear it, he would have little chance from lithotomy. Mr. Aston Key many 
years since remarked, in Guy's Hospital Beports, that lithotomy would leave 
lithotrity far behind as a successful operative procedure. 

Sir Benjamin Brodie could-not enter into all the points which had been 
brought forward in the discussion. He would, however, speak on one or two 
of them. With regard to his mode of seizing the stone, he thought Mr. Coul- 
son had misunderstood him. His practice was to raise the handle of the for- 
ceps, and seize the stone when it lay in that part of the bladder which was in 
contact with the rectum. In this proceeding all depended on the gentleness 
of the manipulation ; no roughness must be resorted to ; a rough hand might 
produce much evil. A reference to his own practice would prove his position. 
In the first few cases in which he had operated, from not employing sufficient 
care, inflammation of the bladder had followed ; but after that, in consequence 
of his operating in a more gentle manner, no harm had followed in a single 
instance. There had also been no difficulty in seizing the stone, nor even the 
fragments, except on one or two occasions. He objected to the mode recom- 
mended by Mr. Coulson, of turnmg the forceps round, with the view of seizing 
the stone, as dangerous. He, himself, had never seen the bladder injured by 
lithotrity ; but Sir Astley Cooper had mentioned a case to him, in which the 
forceps had been passed through the walls of the bladder into the belly. By 
the plan he had recommended there was no difficulty in seizing the stone, and 
he had found no necessity to lower the shoulders of the patient to effect this, 
except in a very few instances. With respect to the employment of the ham- 
mer, as advocated by Mr. Brooke, he (Sir Benjamin Brodie) contended that 
Weiss's screw crushed the stone as effectually and completely as did the com- 
bined screw and hammer of Heurteloup. All the chief French surgeons now 
used the screw : it was a less formidable operation in appearance, and occu- 
pied a smaller space of time. Allusion had been made to the statement of Mr. 
Key respecting lithotomy ; but he (Sir Benjamin Brodie) knew that long after 
that was made, Mr. Key had repeatedly confessed the great comfort he had 
derived from having been able, in many cases, to substitute lithotrity for litho- 
tomy. Lithotomy was an operation attended with the greatest anxiety to the 
surgeon, and he was better without it when his patients were in his private 
prECctice, and in affluent circumstances, for they rarely consented to an opera- 
tion, until the kidneys had become diseased, or some other formidable compli- 
cation had taken place. He mentioned that Cheselden had performed 280 
cases of lithotomy, and had only lost tAventy. It was probable that three- 
fourths of them were children. Cheselden, in later life, had met with a num- 
ber of unfavourable cases ; and it might be questioned how far his early retire- 
ment from practice might have been influenced by the mortification attending 
these failures. — Lancet, March 24, 1855. 

49. Large Prolapsus of Rectum successfully treated luitli Nitric Acid. — Dr. 
Christopher Fleming, of Dublin, records [Dublin Medical Press, April 25, 
1855) the following interesting example of this : — 

A man, 24 years of age, of an unhealthy, strumous aspect, was admitted into 
the Richmond Hospital, March, 1853, labouring under an enormous protrusion 
of the anus and rectum, which rendered his life miserable. His countenance 
was pallid, his frame attenuated, and the smell from his person most offensive, 
his clothes being saturated with the profuse discharge from the anus, which 
escaped involuntarily, even when there was no protrusion. From childhood he 



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was delicate, having had repeated diarrhoeal and dysenteric attacks, to the last 
of which he attributed the date of his present disease, when about 12 years of 
age. At this period, and up to that of 15, he was apprentice to a tobacco 
manufacturer, subsequent to which his occupation was uncertain, but always 
laborious, being latterly that of a hodman to a bricklayer. During all this 
period his habits have been most irregular, his sufferings from hardship and 
from his disease extreme, and his diet uncertain and innutritious. At the age 
of 15, he contracted syphilis, and underwent protracted mercurial treatment. 
For his present disease he has been in hospital, but left without any apprecia- 
ble benefit. He cannot remain for any time in the erect posture without the 
escape of the protrusion at the anus. He has constant and urgent desire to go 
to stool, and passes large quantities of fetid discharge, tinged with blood. The 
escape of feculent matter is most irregular, both as to amount and consistence, 
and is always accompanied with a sensation as if the whole contents of the 
abdomen were escaping, and with protrusion at the anus of a considerable 
tumour, which he is obliged to replace, or subject himself to extreme agony. 
There is a persistent, dull pain and uneasiness in the region of the rectum and 
pelvis, and his sufferings are less acute when the feculent discharges are solid 
than otherwise. He has little or no appetite, often nausea and vomiting, and 
is much tormented with flatulence — in fact, all the symptoms of aggravated 
dyspepsia are present. Under no circumstances has he irritability of the blad- 
der. In the absence of any protrusion, the anus is patulous, and its circum- 
ference, covered with muco-sanguineous discharge, presents numerous ulcerated 
chinks in the direction of its rugae. It is so wide, and the sphincter so relaxed, 
that a gaping, funnel-shaped cavity is exposed, within which the fingers, placed 
conicaily, passed with ease. It, and the greater portion of the rectum, protruded 
on the slighest exertion, and constituted a tumour of considerable size, present- 
ing somewhat the appearance of a prolapsed uterus. The circumference at its 
base exceeded, by measurement, nine inches ; and a line drawn from the base to 
the free end, where the orifice of the bowel existed, reached beyond four. The 
mucous membrane hung in loose, pendulous, and concentric folds, coated over 
with the ordinary tenacious and slimy secretion seen in such cases, and its sub- 
mucous tissue was thickened with copious infiltration. Its surface when first ex- 
posed was of a bright red, which, in proportion to the duration of the prolapsus, 
assumed a dark congested modena colour. It presented irregular patches of 
ecchymoses, of adherent lymph, and of extensive ulceration. It was by no 
means sensitive to pressure. On introducing the two forefingers within the 
intestinal orifice, grasping the protruded intestine between them and the thumb, 
and measuring the intervening depth from the anus, there was so much of 
thickness as to give the sensation of the complete prolapse of the bowel. It 
was curious to remark how he restored this vast protrusion, and sometimes he 
did so by muscular efforts alone, without the slightest manual help. He bent 
forward, pressed his hands on his knees, when a gradual diminution took place 
in the bulk of the protruded bowel, and with a sudden gulp it disappeared, all 
being apparently effected by a combined and violent muscular effort. Again, 
he failed in this, and was obliged to assist it with his hands. It is unnecessary 
to specify the details of treatment during the months of March and April, fur- 
ther than to state that the horizontal position was enjoined, diet properly regu- 
lated, the regular action of the bowels insured, and all the ordinary local means 
a,dopted to restore the healthy condition of the protruded bowel. On the 16tli 
of April, although much dissatisfied, he acknowledged some improvement as to 
the amount of protrusion, and as to the discharge from the bowel, and the latter 
was obvious from the altered state of his linen, which was considerably less 
stained. The ulcers around the anus had a much more healthy appearance, 
and the rectal mucous surface was less loose and pendulous, much less con- 
gested, and the excoriated and ulcerated patches healed; yet the protrusion was 
considerable. Any operative measures appeared to me quite unsuited to his case, 
as well from the nature of his constitution as from the large extent of surfaces 
which should be necessarily implicated in them. It occurred to me that the 
object sought by such could be accomplished by another expedient ; and with 
that view I formed four equidistant radiated tracts with concentrated nitric 



1855.] 



Surgery. 



235 



acid, commencing them near the intestinal opening, at the apex of the protru- 
sion, and passing them as near as I could calculate to the upper margin of the 
inner sphincter. The breadth of these tracts was about a quarter of an inch, 
and the length two inches or so. They were well smeared with oil, and the 
bowel carefully returned. No pain was complained of during or subsequent 
to the application of the acid, which could be justly attributable to it — it was 
similar to that always complained of — it was relievable by the same expedients 
— it was not more severe during the act of defecation. There was no vesical, 
no abdominal irritation. From day to day there was noticed a diminution in 
the amount and in the frequency of the protrusion, and the irritability and un- 
easiness about the rectum and verge of the anus were less. 

April 30. Fourth day from the application of the acid ; report most favourable 
as to the progress of the case, and the sensations of patient; all prominent symp- 
toms improved. I made a careful examination of the rectum, and found in the 
nitric acid tracts many deep, ulcerated sulci, with defined edges ; the lateral 
ulcerations were much more marked than the anterior or the posterior ; there 
was no tenderness of any amount worth noting, and there was decidedly less 
of laxity of the mucous membrane. The ulcers at the edge of the anus were 
more healthy ; I touched them over with sulphate of copper. 

25i!A. Progress good ; discharge from the rectum and anus much less ; local 
uneasiness comparatively slight ; general health greatly improved, and feeling 
of great comfort and relief experienced in consequence of the absence of tenes- 
mus and frequent prolapse, as heretofore. Feculent discharges once daily, and 
without pain, and subsequent easy returns of bowel. 

Improvement in every particular progressive; obvious diminution in 
bulk and shape of protrusion, and mucous membrane much more tensely spread 
over it; ulcerated patches visible, but more limited and superficial ; proportionate 
decrease in discharge. Two ounces of an astringent lotion to be thrown into 
rectum morning and evening. 

May 3. Fifteenth day from first application of nitric acid ; report most satis- 
factory; protrusion of bowel less frequent, occurring only once in twenty-four 
hours ; mucous discharge also much diminished ; defecation natural and with- 
out pain: can cough, sneeze, and use any exertion without any protrusion; 
also walks about without any annoyance ; outlines of previous ulcerated patches 
merely visible, and intervening portions of mucous membrane much more fixed, 
but yet loose and flabby. Pencilled those spaces with nitric acid, as in the first 
instance, but less extensively ; efi'ect apparently now more productive of pain, 
yet not very acute, and easily controlled by hip-bath and anodyne enema. 
Complete subsidence of all uneasiness after a few days ; subsequent steady and 
progressive improvement in tone and in functions of bowel, so much so that on 
the 14th of May the patient was very much improved. The bowel has not now 
descended for many days ; its contents are discharged regularly once in the 
twenty-four hours, and without pain, and without any appreciable amount of 
prolapsus, and the discharge from the anus is much less. 

Further more minute details of progress or of treatment would be here inap- 
propriate. The case was witnessed whilst in hospital, at its difi'erent stages, 
by a very intelligent and observant class of pupils. The man left of his own 
accord on the 4th of June, having then had full control over the prolapsus, and 
the most healthy action of the bowel being established. He moved about with- 
out any inconvenience ; was recommended to go to the sea-side, to bathe, and 
to attend to the state of his bowels. In August, he called on me, on his way 
with his fellow-workmen to see the Industrial Exhibition, and expressed him- 
self as being perfectly free from the prolapsus or any other annoyance. I then 
examined the rectum, with Dr. McKenzie, of Edinburgh, who happened to be 
in my study at the time, and heard his report of his condition. The anus was 
loosely contracted, yet not patulous, and the ulcerations around appeared to 
have perfectly healed. 

There is every reason to assume that the cure has been permanent. 

The very exaggerated form of prolapsus in this case is of rare occurrence in 
adult man, in the absence of injury or of disease, causing an inefficient, if not 
complete suspension of the action of the sphincters. Doubtless, very large pro- 



236 



Progress of the Medical Sciences. 



[July 



trusions of the anus and of the rectum do occur, singly or conjointly, arising 
from causes not now under consideration. The operative proceedings suggested 
by different authors may be suitable to special examples of those cases ; but 
they are in very few, indeed, that I am aware of, persistently beneficial, and in 
all they are more or less hazardous. Those operations have for their object, 
mainly, the more perfect and the more complete closing of the sphincter, either 
by its shortened and divided fibres, or by the consolidation of such v\rith the 
anal orifice, tegumentary or mucous. I am of opinion, however, that the result 
of the above case may lead to the hope that a milder mode of proceeding may 
be adopted, and that the agglutination of the mucous wall of the rectum to its 
muscular, by the establishment of healthy inflammatory action, can be effected 
in the manner I have detailed, so as to enable the special muscles about the 
lower aperture of the rectum to perform the natural and requisite offices. More- 
over, the cicatrization of the several ulcerated chinks, the necessary result of 
the procedure, will tighten up the mucous membrane, so as to render permanent 
such union. In the particular locality I have marked, away from the external 
orifice, the mucous membrane appears to be as little sensitive as the tracheal 
mucous membrane is distant from the larynx ; and hence the comparative free- 
dom from pain in the application of the remedy. 

50. Nitrate of Silver for the Cure of Prolapsus Ani. — Mr. Lloyd treats pro- 
lapsus ani by smearing the whole surface of the protruded bowel with solid 
caustic, and then returning the bowel. The application is repeated once in 
a week or fortnight, as may be requisite. Mr. Lloyd states that he rarely 
found it necessary to employ it more than three or four times; and further, 
that although the plan had been one invariable resort with him, for along series 
of years, that he had never known any untoward consequences to result. In 
cases in which the protruded bowel has become swollen, and is difficult of re- 
duction, the effect of the caustic is surprising. In one such case, the mass 
could be easily seen to diminish in size under its influence. Mr. Lloj^d does not 
limit the use of this remedy solely to prolapsus, but adopts it also in cases 
of hoemorrhoidal congestion, and thickening of the mucous membrane about 
the verge of the anus. — Med. Times and Gazette. 

51. Particular Method of Applying Cauterization for the Reunion of Anoma- 
lous Fissures, and especially those of the Palate. — M. Cloquet proposes, in divi- 
sions of the velum palati, to take advantage of the great amount of retraction 
which occurs in the cicatrix consequent on burns. 

We need not in such cases, says M, Cloquet, cauterize the edges of the fissure 
throughout their whole length, converting them into a granulating sore, the 
cicatrization of which must be afterwards assisted by sutures, appropriate band- 
ages and the maintenance of correct adaption. This method, long known to 
the profession, sometimes succeeds, but often entirely fails. The one which I 
propose, adds M. Cloquet, consists in applying the cautery to the augle of the 
fissure, and that only to a limited extent; leaving the contraction of the cica- 
tricial tissue to operate, and then, practising a similar cauterization, and wait- 
ing for some time to renew the application in such a way as by repeated opera- 
tions to bring the edges of the division towards each other, and to unite them 
by a succession of cicatrizations which may be regarded as so many successive 
points of suture. The double advantage is thereby gained of being thus enabled 
to watch, step by step, the results of the treatment, and to obtain unions of the 
most difficult nature by an operation, simple, scarcely painful, and exempt 
from all danger. It is especially in fissure of the palate that M. Cloquet con- 
siders the advantages of this mode of operating as incontestable, and he men- 
tions four cases in all of which the operation had been attended with equally 
successful results. There had been no pain felt, no change in habits or regi- 
men necessary, and no complications had arisen. The operation was of the 
most simple nature, every surgeon could perform it. It required the aid of no 
assistant, an advantage of great importance in country practice ; and, lastly, it 
could bo practised on very young children. One objection urged against this 
method was the length of time required for completion of the cure, but the 



1855.] 



Surgery. 



237 



slowness of its action constituted its safety, and the inconvenience arising in 
this way was very small, as the patient experienced no alteration in his health 
or habits during its progress. 

The cauterization may be effected by two different means ; namely, either 
by caustics or the actual cautery. M. Cloquet states that in the first of those 
cases where he attempted this method, he used, as the cauterizing agent, the 
acid nitrate of mercury, and succeeded completely. However, he prefers the 
actual cautery, its action being deeper, almost instantaneous and consequently 
less painful, while it occasions a more firm cicatrix, and one which becomes 
more rapidly organized. The three other patients were treated in this manner, 
and the results obtained confirmed his opinion on this point. An almost insur- 
mountable obstacle to its employment might be, however, occasionally met 
with in the terror of the patient. But, fortunately, science provides us with a 
means of obviating this inconvenience ; as a platina wire introduced within the 
mouth, before the electric circuit is completed, cannot excite the patient's 
alarm, and as it can afterwards by this means be brought to a Avhite heat, and 
be kept incandescent for any length of time, the surgeon is enabled to act Avith 
all the calmness and precision desirable. — Monthly Journal of Medicine, May, 
1855, from Gazette Medicate, March 3. 

52. On the Employment of Traclieotomy in Croup. — M. Trousseau loses no 
opportunity of bringing before the Profession the claims of this operation, 
which he believes have not met with due acknowledgment, especially in 
Britain. He states that his employment of it has been more successful than 
ever during the last year, for of nine operations he has performed, recovery has 
been the result in seven. During the last four years he has operated 24 times 
in private practice with 14 recoveries ; and at the Hopital des Enfants Malades 
tracheotomy was performed 216 times, with 47 recoveries, almost a fourth. 
This is a considerable result when we consider the social condition of the 
children brought to the hospital, the injudicious treatment they had usually 
already been submitted to, and the disastrous condition in which they are 
placed after the operation, surrounded by various foci of contagion, so that 
when all seems going on well, scarlatina, variola, or pertussis may induce the 
most dangerous complications. M. Trousseau feels convinced that in civil 
practice success will attend full one-half of the operations, provided they be 
undertaken under conditions rendering success possible. This qualification is 
important, for if diphtheritic inflammation has deeply contaminated the system, 
so that the skin, and especially the nasal fossae, exhibit the special phlegmasia, 
if the frequency of pulse, delirium, and prostration indicate a complete poison- 
ing of the system — the peril being rather in this general condition than in the 
local lesion — the operation should never be attempted, as it is then always 
fatal. But if the local lesion constitutes the principal danger, at whatever 
degree the asphyxia may have arrived, the child having but a few minutes to 
live, tracheotomy will succeed almost as well as if performed three or four 
hours sooner. 

M. Trousseau has now performed the operation above 200 times, and he par- 
ticularly insists upon its being executed with due deliberation, without any 
attempt at display. The double canula must always be employed, and as 
large a one as can conveniently enter the trachea. The operation completed, 
the most urgent thing to attend to is the feeding of the child, for, under the 
influence of abstinence the absorption of external miasmata, and of the vicious 
secretions fabricated within the body is favoured, and the power of resistance 
is enfeebled. Without gorging the child with food its appetite when present 
must be satisfied, while when there is none it must still be forced to eat, and 
by feigning intimidation M. Trousseau has got children to eat who otherwise 
would have been lost. Milk, eggs, chocolate, and broths form the most suit- 
able diet. 

The much greater success which has attended his operations in late com- 
pared with former years, M. Trousseau attributes in part to practitioners not 
previously exhausting the patient's strength by bleeding and blistering so 
much as formerly. After the operation, all medicinal treatment must be dis- 
No. LIX.— July 1855. 16 



288 



Progress of the Medical Sciences. 



[July 



continued, as interfering^ with due alimentation. If blisters have been already 
applied, they must be healed up by means of rhatany or Goulard ointment, 
pencilling the surface with nitrate of silver if diphtheritic exudations be present; 

Apologizing for the apparent minutia3 to which he calls attention, he ob- 
serves, that the longer he lives the more he is convinced of the importance of 
such details in therapeutics. Between the canula and the skin a small strip 
of oiled silk or caoutchouc should be interposed, and the relatives should be 
taught to remove and cleanse the inner canula every two or three hours. The 
neck should be surrounded by a knitted comforter or a large piece of muslin, 
and the inf\int should breathe into this, so that the inspired air may become 
impregnated with some of the warm vapour furnished by expiration. This 
precept is very important; for by its aid we prevent the drying of the cavity 
of the canula and the trachea, and thus avoid irritating the mucous membrane 
and the formation of coriaceous crusts, which, becoming detached, may cause 
dangerous suffocative paroxysms, by obstructing the tube. Before the author 
and M. P. Guersant adopted this plan, they lost several patients by catarrhal 
pneumonia, which is now of much rarer occurrence. Another practice, in the 
neglect of which a cure is rare, consists in thoroughly pencilling the entire 
surface of the wound daily with nitrate of silver. We in this way prevent the 
dangerous formation of thick, fetid, false membranes on its surface. This spe- 
cific inflammation may also become propagated to the cellular tissue and 
develop phlegmonous erysipelas, leading to local gangrene, or at least violent 
symptomatic fever and a general infection of the economy which rarely spares 
the patient. By the fifth day, the surface of the wound has become so modified 
that these accidents are no longer to be feared. 

Finally, the removal of the canula and definitive closure of the wound re- 
quire attention. The canula is rarely removable before the sixth day or later 
than the tenth, and in some cases the larynx remains quite closed for fifteen, 
twenty, or even forty days. At the end of the first week we should take it out 
with great care, so as to avoid making the child cry. The infant having be- 
come accustomed to breathe by the artificial mode, may be seized with a parox- 
ysm of fear and difficult respiration on the first removal. There may be some 
obstruction of the larynx, by slightly adherent false membranes, mucus, or 
• tumefaction ; and the laryngeal muscles may have somewhat lost the power of 
harmoniously contracting. The difficulty of breathing usually soon disappears 
if the child can be kept quiet, and, according to the degree m which the laryn- 
geal passage seems re-established, the wound may be strapped up with court- 
plaster, or left for a day longer covered with ointment or lint. If the air does 
not pass at all, the canula must be replaced for a while longer. "When respi- 
ration is re-established, the opening in the trachea is usually closed in four or 
five days, and the external wound heals soon after. 

Sometimes after the operation there is a difficulty in deglutition, consisting 
in the passage of fluids through the glottis, and its penetration into the trachea 
and bronchi, creating great irritation. Besides this irritating efi'ect, the child 
acquires an invincible disgust for its food, and will die rather than take nou- 
rishment. The best means of treatment is to avoid liquid diet, giving solid or 
semi-solid substances, allaying thirst by a little cold water, given just before or 
long after the repast, so as to avoid exciting vomiting. The inconvenience 
usually commences three or four days after the operation, and rarely continues 
■longer than from the tenth to the twelfth day. It would seem that the larynx, 
which thus permits liquid aliments to pass, should allow the passage of the 
air also; but it is not so, for if we remove the canula, the passage will be 
found insufficient. M. Archambault, who has paid much attention to this 
complication, believes that it results from the child having, by the use of the 
canula, lost the habit of moving the muscles which close the larynx, in har- 
mony with those which propel the food ; and he has found it advantageous to 
temporarily close the canula with the finger during the attempt at deglutition, 
the child then being obliged to bring the laryngeal muscles into action, and 
the harmony becoming re-established. This stratagem, however, sometimes 
completely fails. — Med. Times and Gaz., April 7, 1855, from Archives Gen. de 
Med., March. 



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Surgery. 



289 



53. Paracentesis Thoracis. — M. Trousseau records the following interesting 
case : A man, aet. 16, was admitted on the fifth day of an acute disease, with 
severe frontal headache, lassitude, and prsecordial pain. There was intense 
dyspnoea, a little cough, a very quick pulse, prominence in the cardiac region, 
increased percussion, dulness at the same point, extending to the second rib, 
and to the right of the sternum ; the heart's sounds were feeble and distant. 
No mention is made of rheumatism, and it is to be presumed that it was ab- 
sent. For a month the effusion continued the same ; only once, for two days, 
did it seem to diminish, and then there was a little friction at the base. After- 
wards, the dyspnoea increased and the fluid augmented as the dulness now 
reached to the clavicle. There was also pleuritic effusion. It was determined 
to puncture the pericardium : this was done by an incision in the fifth inter- 
costal space, three centimetres (= 1^ inch) from the sternum ; thirteen ounces 
of fluid slowly escaped, the cardiac dulness decreased in amount, respiration 
could be heard in the lung as low as the fourth rib. A day or two afterwards, 
the pleuritic effusion was found to have increased ; the heart was displaced to 
the right. Thoracentesis was practised in the sixth space in the axillary line, 
and although at first the canula was blocked up by false membrane, eventually 
sixteen ounces of fluid were removed. Neither pleural nor pericardiac effusion 
reappeared, but, soon after, signs of tuberculosis of the left lung came on. 

The authors refer to the other (7) cases of paracentesis pericardii on record. 
— Brit, and For.Med.-Chirurg. Rev., Jan. 1855, from Archives G6n., Nov. 1854. 

54. Enormous Fibrous Tumour of the Neck extirpated by the method of Morcelle- 
ment — Recoverij. — On the 8th Aug. last, M. Maisonneuve presented to the Im- 
perial Academy of Medicine, a woman, ast. 35, from whom he had removed a 
very large fibrous tumour of the neck, which other eminent surgeons had pro- 
nounced beyond the reach of art. He extirpated it by the method he terms 
morcellement, which consists in dividing it into pieces. He had first employed 
this method in the case of large fibrous tumours of the uterus, which were not 
extricable on account of their enormous size. 

The tumour was of two years' standing, and had latterly increased in bulk 
so much as to render suffocation imminent. It occupied the whole of the left 
side of the neck, and extended vertically from the mastoid process to below the 
clavicle, and transversely from the spinous processes of the vertebrae to behind 
the larynx and trachea, which were considerably displaced by it to the right 
side. The carotid artery and internal jugular vein were visible on its external 
surface. It was slighly nodulated on its surface, and it had the firm resistant 
feeling of fibrous texture. The skin glided with ease over its surface ; but the 
tumour could not be moved over the deep-seated textures. It was not painful 
to touch. The arm was neither painful nor swelled, but retained perfect free- 
dom of motion. M. Maisonneuve diagnosed the existence of a fibrous tumour 
adherent to the transverse processes of the vertebrae, and he considered that the 
important vessels and nerves of the neck were not involved in its substance, for 
two reasons: 1st. The unimpaired condition of the sensory and motory func- 
tions of the head and arm ; and 2d. The fibrous character of the growth, and its 
intimate attachment to the vertebras. His anatomico-pathological researches 
had long satisfied him that tumours which have a periosteal origin always remain 
isolated and distinct from the soft parts in the midst of which they are developed. 
He, therefore, resolved to attempt its removal, and the poor patient, on learning 
his decision, wept tears of joy. Chloroform having been administered, a verti- 
cal incision was carried from the mastoid process to the clavicle, and another 
transversely from the larynx to the spinous processes of the vertebrae. The 
flaps of this crucial incision were laid down, and the tumour was extirpated by 
a long, laborious, and most delicate dissection, in the course of which, the caro- 
tid, the internal jugular vein, the pneumogastric nerve, and the cervical and 
brachial plexuses were exposed. On account of the firm adherence of the 
tumour to the adjacent parts, it was found impossible to extract it en masse ; 
M. Maisonneuve therefore resolved to divide it into two equal portions by a 
•transverse incision. This greatly facilitated his operations ; and saved the im- 
portant structures from injury. Portions of the scaleni muscles were unavoid- 



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ably removed in the dissection. Maisonnenve had to subdivide one of the 
halves of the tumour, but he succeeded in removing the vehole of it, and com- 
pleting the operation in three-quarters of an hour. There vras very little loss 
of blood, owing to the extreme care taken to avoid wounding large vessels ; and 
the patient was under the influence of chloroform the whole time. 

The wound left by the operation was a deep and ghastly excavation, at the 
bottom of which lay the lower six cervical vertebrae, the first rib, the cervical 
and brachial plexuses, the larynx, trachea, pharynx, and oesophagus — all ex- 
posed to view! M. Maisonneuve, anxious to avoid suppuration and obtain 
union by the first intention, brought the tissues together by means of adhesive 
plaster, serres-fines, and properly regulated pressure. In three days, four-fifths 
of the wound had cicatrized, and the remaining portion was filled with healthy 
granulations. In a month the patient was quite well ; the parts around pre- 
served their normal site ; the arm had no impairment of its sensibility or mo- 
tion ; the voice was clear, and deglutition was easily performed. 

The tumour w^as purely fibrous, and of a dense hard texture. It weighed 
475 grammes {i. e., nearly 8 lbs). — Month. Joiirn. of Med. Sci., Dec. 1854; from 
L' Union Medicate, 10th August, 1854. 

55. JExtirpation of the Uterus. — Dr. Reiche states that he has extirpated the 
entire uterus seven times; in all cases the result was fatal. He, however, ad- 
vocates the operation in cases of cancer confined to the organ. He then describes 
the method of operating; this presents nothing calling for analysis. Partial ex- 
tirpation he represents as a painful operation, but one free from danger. It is 
indicated in all degenerations limited to the neck of the uterus. — Brit, and For. 
Med.-Chirurg. Rev., April, 1855, from Deutsche Klin. 43. 1854. 

56. Excision of the Head of the Humerus, hy a New Method. — M. Batjdens, 
in a memoir recently (Feb. 26, 1855,) read before the Imperial Academy of 
Sciences, insists on the duty of endeavouring to enlarge the sphere of conser- 
vative surgery, and to seek to substitute excision for amputation, the idtima 
ratio. This object he has always had in view. In 1836, he announced, in his 
Clinique on Gun-shot Wounds, that " excision should be the rule, and amputation 
the exception, in cases of comminuted fracture of the upper extremities." 
" Since the additional observations made on the hundreds of wounded admitted 
into Val de Grace, in February and June, 1848," adds M. Baudens, "we are 
able to go farther, and to prove that the majority of fractures of the leg, the 
result of gun-shots, may be preserved from amputation by removing the splin- 
ters, and by the application of ice and of our fracture apparatus." Con- 
servative surgery is not merely limited to the avoidance of mutilations, it 
diminishes the mortality [son necrologe est moins chargi que celui de V amputa- 
tion). 

The advantages claimed for excision by M. Baudens are, that it produces 
less shock, leaves a less extensive surface for traumatic inflammation, and is 
more likely to be followed by speedy union. 

M. Baudens has employed excision of the head of the humerus in preference 
to amputation at the shoulder-joint, with the gratifying result of thirteen 
recoveries and but one death ; hence, he feels authorized to reverse an esta- 
blished rule, and to say that ''excision, when a hall has broken the head of the 
humerus, ought to be the ride, and amputation the exception." 

This operation dates back more than a century, having been first performed 
by Thomas, a surgeon of Pezenas (Languedoc), in 1740, for necrosis of the 
head of the humerus. Subsequently, Boucher, in a memoir on gun-shot 
wounds, and after him, Percy and Larrey, showed that by removing the shat- 
tered head of the humerus, the arm might be saved. This operation has been 
most successfully performed by White, Vigarous, Moreau, father and son, etc., 
in cases of disease. 

According to M. Baudens, the real value of the operation has not as yet been 
fully decided. Larrey, he says, thinks that the use of the arm is greatly im- 



1855.] 



Surgery. 



241 



paired, and that the subjects of this operation are unable to raise the arm on 
the scapula.^ 

In 1854, M. Gimelle gave the following opinion, in a report to the academy: 
" Resection of the head of the humerus reduces the arm to impotence; it fails 
like the pendulum of a clock, and is often of more annoyance than use/' M. 
Sedillot gives the same opinion." {Medecine Op^ratoire, p. 497.) From the re- 
sults of M. Bauden's experience, he disagrees entirely with these opinions. 
"On all occasions," he says, "in which excision is limited to the head of the 
humerus, we have always found the motions of the arm to be restored; but the 
new scapulo-humeral articulation becomes a ginglymoid instead of an arthro- 
dial joint." 

I. Means of obtaining a New Articulation. 

In order to obtain a new artilculation, two indications must be rigorously 
carried out. 1. To keep the humerus in immediate contact with the glenoid 
cavity. 2. To take as much care as possible of the muscles and nerves of the 
shoulder. Hence, M. Baudens says, that of the two methods recommended of 
performing this operation, viz: by flap or single incision, he has no hesitation 
in selecting the latter. He objects, therefore, to the operation as performed by 
Moreau, Manne, Sebatier, Bent (of Newcastle), Morel, Syme, etc., all of whom 
employed modifications of the flap operation. The method by single incision 
was that originally performed by White. The difl&culties of this mode of pro- 
cedure, he admits, are greater. These difficulties are stated to be twofold: 
ths first, arising from the energetic contractions of the deltoid muscle, which 
render it difficult to expose the head of the bone; the second, from the head of 
the bone being drawn high up into the coraco-acromial vault by the contractions 
of the scapular muscles. These muscular contractions are the " Gordian knot" 
of the operation. To overcome them, says M. Baudens, the tuberosities are by 
rotation to be alternately brought into the centre of the incision, and the 
muscles divided, and with them the capsule which is confounded with their 
insertions, by which an opening is made sufficiently large to give exit to the head 
of the humerus. These peculiarities, which, according to the author, were not 
previously known, led M. Baudens, in 1833, to modify materially the method of 
White. Instead of making the incision externally (or nearer the acromion), as 
White did, M. Baudens makes it internally, for three reasons: first, because the 
head of the bone is here more superficial ; secondly, because the incision can be 
prolonged as high up as is necessary to expose all the bone ; whilst, thirdly, it 
enables the operator to come down at once upon the bicipital groove, and thus 
upon the muscles (capsular), the division of which forms the key to the whole 
proceeding. " The advice given by authors to cut the capsule first, and the 
four rotator muscles afterwards, is precisely the reverse of what ought to be 
done." The capsule need not be specially sought after ; " all that is necessary 
is to make the section of the muscles, at the same moment the capsule will be 
found to be largely opened ; then the head of the humerus, which had been 
drawn up into the arch beneath the acromion and coracoid processes, and held 
there as if in a vice, immediately descends, and from that moment can easily 
be made to project through the opening in the capsule." 

Mode of operating, as performed by M. Baudens. The operation is divisible 
into four stages or periods: — 

First Stage — The arm being everted, the point of a small amputating knife 
is to be passed directly down to the head of the bone, on the outside of the 
coronoid process, and carried downwards for about five inches, keeping the 
knife in contact with the bone. 

I We scarcely think M. Baudens has done justice to Larrey in this matter. Larrey, 
we are of opinion, has fully established the propriety of excising the head of the 
humerus when practicable. In his work on Military Surgery , he says: "I have had 
the good fortune, on ten different occasions, to supersede the necessity for amputation 
at the shoulder, by the complete and immediate extraction of the head of the humerus, 
or its splinters, without delay; seven were cured, three died." " In some, the arm 
became anchylosed to the shoulder, and in others an artificial joint, allowing of mo- 
tion, was formed." — Translator. 



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Second Stage. — If necessary, cut a few fibres of the deltoid transversely, 
without wounding the skin ; open up the bicipital groove, and cut across the 
tendon of the biceps. 

Third Stage. — Bv rotating the arm alternately inwards and outwards, we are 
able to expose, first, the greater, then the lesser tuberosity, and freely to cut 
across the muscles inserted into them. 

Fourth Stage. — The capsule having been thus opened, the elbow is to be 
carried backwards and upwards, so as to luxate the head of the humerus, and 
make it p^rotrude through the wound; then, with the saw, remove the bone, 
sparing, as much as possible, the posterior attachment of the capsule and the 
periosteum. [M. Baudens attaches much importance to this point, in con- 
sequence of the Lelles decouceries of M. Flourens, on the regeneration of bone 
by the periosteum.] 

Fifth Stage. — Tie the vessels, cover the extremity of the humerus with the 
preserved periosteum, as with a hood, keep it in direct contact with the glenoid 
cavity by propping up the elbow with a bandage, and endeavour to obtain 
union of the soft parts, except at the lower angle of the wound, where a tent is 
to be inserted to allow matter to escape. 

II. Within ivhat limits is the incision to he conjined? 

M. Baudens enters at length into this question. The operation admits of seve- 
ral modifications ; but the grand rule is to save as much bone as possible. Thus, 
1. When the head of the bone is but partially injured, he has been able to re- 
move the half only. This, he says, has never been previously done. 2. All the 
head may require to be removed ; but it is very important not to encroach on the 
anatomical neck, and, at all events, to take care of the attachments of the capsule 
posteriorly. 3. If the anatomical neck of the humerus must be divided, the 
insertions of the muscles are to be preserved as much as possible. 4. In one 
case, where the humerus was greatly comminuted, I removed, says M. Baudens, 
the humerus below the insertion of the deltoid. " Here, the bone being con- 
nected by soft parts only, was deprived of the movements of the scapula, but 
the motions of the forearm and hand were preserved intact. Even here, the 
result was far more satisfactory [magnijir^ue) than is ever obtained by amputa- 
tion at the shoulder-joint." 5. In one case, M. Baudens removed, with success, 
the head of the humerus, the glenoid cavity, the acromion process, and all the 
spine of the scapula. 

III. When the fracture of the head of the humerus extends doic?iwards into the 
shaft [split fracture], is this a case for amputation? 

Larrey does not hesitate to answer in the affirmative. "Amputation," he 
says, "is in that case indispensable." [CI. Chirurg., tome v. p. 183.] This 
opinion, which is likewise that of many other surgeons, is not the opinion 
of M. Baudens. "In four cases," he says, "we were content to remove only 
the head of the humerus, without minding the fissures which ran, more or 
less, down the shaft of the bone into the medullary canal, and recovery took 
place just as if these fissures had never existed." 31. Baudens adds that he 
has often seen, in amputation for gun-shot wounds, longitudinal fractures in 
the bone which formed the stump, from which no unpleasant consequences 
resulted. " The fissures got well as simple fractures do." 

In amputation of the thigh for comminuted fractures, this is a point of much 
importance, as the mortality is much influenced by the proximity of the amputa- 
tion to the trunk. M. Baudens says, the limb should be removed close to the 
fracture; and adds, "that he has more than thirty times carried this rule into 
practice, and never regretted leaving a fissure in the osseous tissue." Longi- 
tudinal fractures, he adds, are so frequent, as the result of gun-shot wounds, 
"that it would be very difficult to avoid them in amputating, as we are often 
in ignorance of their precise extent ; but fortunately they remain unobserved 
as to their results.'"^ 

% 

^ This opinion, we think, should be received with some reserve. In a case of 
comminuted fracture, near the centre of the tibia, we have seen a fissure to extend 
up into the knee-joint, which, becoming inflamed and subsequently disorganized, 
rendered amputation of the thigh necessary. Had the injui-y been so severe as to 



1855.] 



Surgery. 



243 



lY. Is it absolutely necessary to excise the head of the humerus ivhen it has been 
broken by a ball? 

M. Baudens says, from his experience, the operation is always i^equisite. 
When this is not done, we learn that "one of three results are observed: 1, 
death from purulent infection; 2, the necessity for secondary excision; or, 3. 
the patient survives vrith anchylosis, or fistulous openings, in a state of suf- 
fering and peril, the issue of which is uncertain/^ 

Y. Is immediate excision to be preferred to secondary excision ? 

M. Baudens furnishes the following statistics: — 

" In twenty-six cases, the head of the humerus was tlius injured. In eleven, 
excision was immediately performed; ten recovered, one died ; in fifteen, the 
operation was deferred in the hope that, because their wounds perhaps were 
less severe, they might recover without an operation. Of these fifteen, eight 
died of purulent infection ; three underwent secondary excision (all of whom re- 
covered), and four survived with fistulous openings. 

" Hence, we see the success of three secondary excisions was dearly bought, 
since from not having operated at once, eight of the wounded died of purulent 
infection." 

The remainder of the memoir is occupied with illustrative cases, which are of 
extreme interest, and which corroborate the principles laid down in the preced- 
ing pages. 

57. Dislocation of the Astragalus Backwards and Inwards. — Prof. Williams 
communicated the following case of this accident: — 

" Stephen Phillips, labourer, aged 54, of spare habit and sallow complexion, 
who has uniformly enjoyed good health, and lived well and temperately, was 
admitted into the City of Dublin Hospital on the 12th of April, 1852. 

" He states that on the previous day he had been at work, along with some 
other men, beneath an overhanging bank of earth and gravel in the granite 
quarry at Kingstown, which they were undermining and removing in order to 
expose the granite strata underneath. At the time the accident occurred, the 
patient and another man were engaged shovelling the loose earth, as it was 
detached, into a truck or wagon, which was placed behind them on the " tram 
way." Whilst thus employed, another man ascended the bank, and without 
any warning to those below, struck a heavy iron bar, called a "clay bar," 
into its upper surface, when it suddenly gave way, and being precipitated over, 
struck the patient violently on the left side of the thorax (he was on the side 
of the wagon next the falling earth), he standing with his chest parallel with 
the front of the bank previous to its fall ; but lohen str^ucJc, his body was par- 
tially rotated backwards and to the right side, as he was in the act of throwing 
a shovelful of earth into the wagon, which stood behind and to the right side 
of him. The force of the concussion threw him violently backwards across the 
roadway. The remainder of the earth fell over the lower part of his body, fix- 
ing his feet and legs to the ground. Though very much hurt, he says he was 
not at all confused, and describes the accident as having taken place exactly as 
above stated. He also says that he does not think the mere weight of the fall- 
ing earth was sufficient to produce the injuries received, as he was easily able 
to withdraw the injured limb without assistance; the right leg having been 
more heavily covered, had to be dug out before he could be completely extricated. 
He says he suffered acute pain in the left ankle from the moment of the acci- 
dent, and it soon became swollen, and he also had severe pain in the left side 
of the chest. He was carried to a house in the neighbourhood, and the next 
day was admitted to the City of Dublin Hospital under the care of Dr. Wil- 
liams. 

" He complained of pain and a stitch on taking a full inspiration in the left 
side of the chest, and on examination the fifth and sixth ribs of the left side 

require araputation, in the first instance, according to M. Baudens' rule, it should 
have been performed just above the seat of fracture, and in that case, secondary 
amputation would have been required for the subsequent disorganization of the knee- 
joint. The case alluded to was treated in the Richmond Hospital by Dr. Hutton. — Tr. 



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Progress of tlie Medical Sciences. 



[July 



were found to be fractured about their centres. The left ankle-joint presents 
some curious and unusual appearances. The anterior relations of the tibia are 
very little disturbed, the anterior aspect of the foot being free from deformity, 
except indeed a nearly imperceptible shortening of the foot, which is a little 
everted. He has free motion of his toes and some slight motion of the ankle- 
joint. Motion of the latter increases the pain, which is of a " burning" cha- 
racter. There is no fracture of either the tibia or the fibula, and there is some 
swelling and ecchyraosis, with a hard tumour of an irregularly convex shape, 
lying between the inferior extremity of the tibia, the tendo-Achillis, and os 
calcis. Professor Williams came to the conclusion that this tumour was formed 
by the astragalus, which was dislocated backwards and inwards, and also so 
rotated on its antero-posterior axis that its superior articulating surface looked 
almost directly inwards. A slight attempt was made to replace the bone, but 
was speedily abandoned, both because of the impediment to reduction presented 
by the above-mentioned rotation, and of the risk of further injury to the swollen 
and ecchymosed soft parts covering the astragalus. The limb was then placed 
on a double inclined plane, so arranged that the leg lay horizontally. Leeches 
were applied to the joint, and subsequently cold water irrigation.'^ 

Professor Williams said he would not detain the Society by reading the de- 
tails of the progress of the case, which had been fully and accurately taken by 
Mr. Taylor. It would be enough to say that the soft parts covering the dis- 
placed bone inflamed, and on the eighth day, when it was evident that their 
destruction was inevitable, they were divided by a crucial incision, which gave 
exit to a little sanious discharge, and exposed the bone with its superior arti- 
cular surface looking inwards. On the fourteenth day the bone was removed 
(some strong ligamentous attachments, which still held it, being divided with 
a probe-pointed bistoury guided by the forefinger), and it was then found that 
the astragalus had been fractured as well as dislocated, its head and a portion 
of the inferior surface having been broken, or rather ground ofiF, and a quantity 
of the resulting small fragments were removed. The limb was then replaced 
in its previous position. Nothing requiring to be particularly noticed occurred 
until a fortnight after the removal of the bone, when an abscess formed below 
and behind the external malleolus, and was opened. The discharge both from 
this abscess and from the cavity from which the astragalus had been removed, 
now rapidly diminished, and the parts presented a very healthy appearance. 
Matters went on favourably till about 6th of May, when some trouble was 
occasioned by stripping of the integuments over the sacrum and os calcis, in 
spite of every precaution that had been taken to guard against both. This, 
however, was remedied by attention to position, and on the 7th of June the 
limb was replaced in its original posture. From this time he went on steadily, 
but very slowly, improving ; and on the 10th of August the cavity whence the 
bone had been removed had cicatrized, leaving a deep depression. 

The foot Avas in an exceedingly slight degree extended, but not permanently 
so, for he possessed some power of moving the ankle and was able to bring 
the foot to a right angle with the leg. He now began to move about on crutches, 
and at first the foot, when allowed to depend for some time, became painful and 
oedematous, but that inconvenience was relieved by careful bandaging, and soon 
ceased. Towards the latter end of August he left the hospital to go to the 
country, and was then able to walk pretty well with the aid of a stick. 

Nothing was seen or heard of the patient until ten months after he had left 
the hospital, when he returned and stated that he had resumed work, though 
not of so laborious a kind as before, but that the extension of the foot had 
gradually increased, so as to cause considerable inconvenience in walking. The 
tendo-Achillis was now divided subcutaneously, and the foot was brought to 
about the same position it had been in when he first left the hospital. He was 
then provided with a high-heeled shoe, and left the hospital considerably im- 
proved, but using the help of a stick in walking. 

Professor Williams said he was chiefly induced to bring this case before the 
Society, because it was rather curious so little attention has been directed to 
dislocation of the astragalus backward; in fact, it has been scarcely noticed by 
systematic writers on surgery. Benjamin Bell, indeed, says that the astragalus 



1855.] 



Surgery. 



245 



may be displaced backwards, but he apparently does so wholly on theoretical 
grounds, and merely as contemplating the possibility of the occurrence ; but 
Professor Williams could not then remember any other systematic writers who 
alluded to the subject, except Mr, Lizars and Mr. Liston, who have each very 
briefly mentioned a case that occurred in their own practice respectively, and 
Mr. Liston observes that he never expected to see another. On the other hand, 
this dislocation was not noticed by Miller, Fergusson, Bransby Cooper, Skey, 
Pirrie, or Erichsen, and it had even escaped the great experience and research 
of Mr. South. The French systematic writers were quite silent on the subject. 
MM. Yidal de Cassis and Nelaton, for example, the most recent of them, say 
nothing about it ; and yet it was scarcely necessary to say before that Society, 
that there are several cases of dislocation of the astragalus on record. The 
accident, however, was undoubtedly a rare one, as only six cases of it, he be- 
lieved, had hitherto been published; and the fact that so few cases of the kind 
had yet been recorded had chiefly induced him to bring before the Society the 
present case, which would make the published examples of dislocation of the 
astragalus backwards amount to seven in number. There were, however, one 
or two points respecting which he would say a few words. 

The six cases already known are collected by Mr. Turner in his valuable 
monograph on " Dislocations of the Astragalus'^ (together with a case inadver- 
tently quoted from Boyer as an example of that accident) ; and in two of those 
cases (Mr. Phillips') the bone appears to have been thrown directly backwards, 
as it is stated that in one the tendo-Achillis was forced back by the bone, so as 
to form an angle of 45 degrees, and that the appearance in the second case was 
exactly similar. In one case (Mr. Turner's) the displacement was backwards, 
outwards, and downwards ; and in three (those of Mr. Lizars, Mr. Liston, and 
one recorded in the Lancet, that was admitted to University College Hospital), 
the astragalus was dislocated backwards and inwards. In the case read that 
evening, the displacement was also in the latter direction, so that in four of the 
seven cases now known, the astragalus has been backwards and inwards. 

In only one of these seven cases (that recorded in the Lancet) was either the 
tibia or the fibula fractured ; and in that case both those bones were broken at 
the level of the ankle-joint. This case is also the only one of the seven in which 
reduction was effected ; and as Mr. Turner observes, the existence of fracture 
of the bones of the leg no doubt facilitated the reduction. 

In one case (Mr. Turner's) the bone was removed, the dislocation having 
been compound, complete, and irreducible; and in four (Messrs. Phillips, Lizars, 
and Liston's) reduction being impossible, the bone was left in its new situa- 
tion ; in all these cases the patients did well, and had ultimately a useful limb, 
without death of the bone, suppuration, ulceration, or sloughing of the integu- 
ments. In the case read that night the result was different, as had appeared 
from the report of the case. This, then, was the first case of dislocation of 
the astragalus backwards, in which the soft parts inflamed, and sloughed, and 
exposed the bone. 

It is stated in Mr. Taylor's notes of the case that the attempts made to reduce 
the bone were not forcible, and were soon abandoned. The reasons for not 
making much or persevering effort at reduction were (Professor Williams said), 
that as soon as he had satisfied himself the bone had sustained about a quarter 
of a complete revolution inwards on its antero-posterior axis, so that its supe- 
rior articulating surface looked directly inwards, he saw little prospect of effect- 
ing reduction, inasmuch as that deviation could scarcely be rectified by any 
force that could have been brought to bear on the bone, and even if it were 
practicable, it could not have been effected without inflicting an unjustifiable 
amount of injury upon the soft parts covering the bone; the attempt at reduc- 
tion, therefore, was very slight ; so slight, indeed, as scarcely to be called an 
attempt at reduction ; and, moreover, the history of previous cases of the acci- 
dent tended to show that, on the one hand, there was little hope of replacing 
the astragalus when the tibia and fibula were unbroken ; and on the other, that 
in every instance in which the bone had been left in its new situation the issue 
had been satisfactory. As to the rotation of the astragalus, that bone could be 
rotated either on its antero-posterior or transverse axis. In Mr. Liston's case, 



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the astragalus was rotated in the latter direction ; and in Mr. Turner's it was 
rotated on its antero-posterior axis outwards, the superior articular surface pre- 
senting at the wound. In the case just read the bone had made a quarter of a 
revolution inwards, Professor Williams said he need not dwell upon the mechan- 
ism of the various rotations of the astragalus in dislocation; for whether the 
rotation was partial or complete; whether on the antero-posterior or transverse 
/ axis ; or whether it occurred in dislocation forwards or backwards, the mode of 

its production was analogous in each case, and explicable on the same princi- 
ples. But the recognition of the existence of such a rotation was of great 
importance, for when it existed to any considerable extent, Professor Williams 
thought it rendered reduction impracticable. Xow, the outlines of the astra- 
galus are so well marked and recognizable by the touch, and the exact position 
was so clearly made out in this case of dislocation backwards, where the soft 
parts covering the displaced bone are so much thicker than in dislocation for- 
wards, that he could not but think the existence and extent or non-existence of 
rotation could be easily determined, at all events in most cases, and especially 
in anterior dislocation ; and thus an important guide as to the treatment to be 
adopted would be obtained. 

The notes of the case were illustrated by a cast, showing the appearance of 
the ankle and foot on the day the patient was admitted into the hospital, and 
by a drawing and coloured wax cast, taken by Dr. Alexander Carte, exhibiting 
the position of the astragalus, and the condition of the surrounding soft parts 
on the day the astragalus was removed. 

Mr, Tufnell has in his possession a cast of the patient's foot in his present 
condition, and perhaps he would have no objection to exhibit it to the Society 
at their next meeting. 

Mr. Tufnell. — I will be able, I think, to do more than that, for I may possibly 
be able to bring you the man himself. I met him the other day in the street 
when he was walking with one stick; he formerly required two, but latterly he 
said he had discontinued one of them. I asked him whether he was able to 
carry a basket on his arm and to work for his living, and he replied that he 
could not. Now, this is an important point to bear in mind. 

Professor Williams. — I have no hesitation in saying that on several points 
the treatment of dislocation of the astragalus requires to be very carefully re- 
viewed, and that Mr. Turner's statistics are not sufficiently extended to justify 
some of the conclusions which have been drawn from them. I have myself col- 
lected a considerable number of cases in addition to those that are reported in 
his work, and I hope on some future occasion to bring the subject at greater 
length under the notice of this Society. As regards the question of leaving the 
bone in situ, this much is to be said, that if authority deserves to have any 
weight, we have in favour of doing so the great names of Sir Astley Cooper, 
Dupuytren, and other surgeons of eminence, who did so even in some cases 
where it was anticipated that the parts covering the bone were likely to slough. 
— Dublin Medical Press, April 4, 1S55. 



OPHTHALMOLOGY. 

58. Protrusion of the Eyeballs, with Enlargement of the Thyroid Gland and. 
Anaemic Palpitation. By James Begbie, M. D. — J. K., aged 32, by occupation 
a gentleman's servant, many years ago had a fall from horseback, by which he 
sustained a severe wound on the occiput, from which a profuse and continued 
hemorrhage took place. He has never been quite well since that occurrence. 
In the beginning of 1845, he suffered from bilious fever, and made a slow and im- 
perfect recovery. In August, 1851, had an attack of jaundice, which continued 
more or less for a whole year; and during its progress the symptoms which first 
attracted attention in connection with the present history developed themselves. 
For more than a twelvemonth he has been subject to palpitation, breathlessness, 



1855.] 



Ophthalmology. 



247 



and giddiness. These symptoms were soon followed by eDlargement of the 
thyroid gland, and by increased prominence and distension of the eyeballs, so 
as to give him a remarkable appearance of staring, which was noticed by all 
his friends. 

In the spring of 1853, he first came under my observation. He was a man 
of middle size and well formed. His countenance was pallid and sickly; but 
under excitement, either mental or bodily, his face quickly flushed, and his man- 
ner became nervous and embarrassed. At all times, but especially under ex- 
citement, the action of the heart was forcible and rapid, and this action was 
communicated to the vessels of the neck and head. The eyeballs were enlarged 
and prominent, presenting the appearance of great distension. The thyroid 
gland was also much enlarged throughout its whole body, varying in size accord- 
ing to the force of the heart's action. This enlargement was accompanied by a 
strong pulsation over the tumour, and in the vessels of the neck ; and a pecu- 
liar thrill was felt, and a loud murmur heard, over the whole extent of the 
gland. The action of the heart was violent and jerking; and a loud bellows 
murmur attended the first sound, and was heard most distinctly over the region 
of the aortic valves. In a state of quiet and rest these symptoms became mo- 
derated, and the patient was able to continue his domestic service, in the enjoy- 
ment of comparative health. He was directed to take persistently for months 
the milder preparations of iron, and to use a diet chiefly of animal food. Under 
this plan he improved in health, and all his more urgent symptoms subsided 
by degrees. In the autumn of 1853 he went to England, and continued, I under- 
stand, to improve in health : but I lost sight of him at this time. Early in the 
spring of 1854, he had engaged to accompany a distinguished ofl&cer to the 
Crimea, as his body-servant. Before the time arrived, however, when he was 
to have entered on his duties, he was, after exposure to cold and fatigue, seized 
with inflammation of the chest, and obliged to relinquish the undertaking. His 
illness was severe and continued, and he never recovered from it. It appears 
to have aggravated greatly the peculiar symptoms under which he had so long 
laboured, and complicated the aspect of his case. He was able to return to 
Scotland, however, and in March, 1854, he again, after an interval of several 
months, came under my notice. At this time, he had enlargement of the liver, 
•with jaundice, and the signs of organic disease of the heart, accompanied with 
general dropsy. His eyes were still prominent, and the thyroid gland enlarged, 
but neither of these now maintained the striking character which they possessed 
previously to his leaving Scotland. No remedy was of any avail, and he sank, 
on the 28th of March, worn out with the sufi'erings of complicated disease in 
the thorax and abdomen. The body was opened on the 30th by Mr. Johnston, 
in presence of Drs. ^Y, T. Gairdner and "Warburton Begbie, and myself. 

Sedio Cadaveris. — March .^0, 4 P. M. Body of a moderately stout and mid- 
dle-sized man. The linens in which the body was shrouded were in many parts 
(as the neck, axilla, scrotum and legs) quite soaked with serous fluid exuded 
from the body. The cuticle was in many parts loose and easily detached from 
the cutis vera, and in every organ of the body examined, signs of decomposition 
were generally met with — frequently so marked as to obscure the proper patho- 
logical conditions. 

The subcutaneous tissue, and indeed the cellular tissue generally, contained 
very little fat, and was in every part more or less infiltrated with serum. 

On opening the thorax, the pericardium was found of large size, and over- 
lapped, at its sides only, by the margins of the lungs. It contained about six 
ounces of a transparent yellow-coloured fluid. Upon the anterior surface of the 
heart, near to its base, a " milky spot'"' was observed, about the size of a florin- 
piece, and another upon the opposite surface of the pericardium. 

All the cavities of the heart were filled with dark-coloured blood in a more 
than usually fluid condition; one well-formed decolorized clot was found in the 
right ventricle. The heart was large (might have weighed 16 oz.), soft, and 
flaccid. All its chambers, but more especially the ventricles, were considerably di- 
lated; the tricuspid orifice admitted ybu/* fingers, the mitral three. The tricuspid 
and mitral valves were large, but otherwise normal; the sigmoid valves were 
also normal. The vena cava inferior was unusually large : and the aorta v/as 



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small when compared with the size of the pulmonary artery. The endocardium 
and inner surface of the aorta were stained of a deep red colour. 

Both pleurce contained turbid fluid of a dark red colour, computed at about 
eight or ten ounces in each. The posterior surface of the upper lobe of the 
right lung was firmly adherent to the costal pleura by strong short bands of 
lymph. The lower lobe of this lung was crepitant, and infiltrated with bloody 
serum; the posterior part of the upper lobe was condensed, non-crepitant, and 
friable, as if hepatized; but the advanced state of decomposition in which it 
was, prevented a decided opinion being formed concerning it. The left lung 
was crepitant, with the exception of its posterior part ; and from the surface of 
a section a considerable quantity of bloody serosity was readily expressed. 

The sterno-hyoid and sterno-thyroid muscles were much thinner and broader 
than natural, from being stretched over the thyroid body, which were of large 
size. The external jugular vein was normal; the internal jugulars were large 
— the left one, when slit open, measured an inch and a half across at a level 
with the cricoid cartilage. The thyroid body was of large size, but was not 
weighed; its weight may, however, be computed at being four or five times 
greater than natural. Each lateral lobe measured an inch and a half in breadth, 
and was of a corresponding thickness. This great increase in size was not 
partial but general, and although the isthmus was comparatively larger than 
the lateral lobes, there was complete symmetry of both sides. It was of a dusky- 
red colour, smooth, and well-defined, and slightly irregular on its anterior sur- 
face, but still retained the natural convex and semi-lunar form of the organ 
when in a state of health. 

The peritoneum contained about a pint and a half, or two pints, of a clear 
fluid, tinged of a bright yellow. The spleen was enlarged in all its diameters, 
and was computed to weigh about twenty ounces. It was of very firm consist- 
ence, and on section presented the trabeculse well-marked, and also the Mal- 
pighian bodies, which were of an opaque yellowish-white appearance. The 
kidneys were both very large and very soft. The cortical was to the medullary 
substance, relatively, increased in amount, and the great size of both organs 
seemed to arise from this circumstance ; otherwise their actual pathological con- 
dition could not be ascertained on account of the advanced state of decompo- 
sition which they were in. The liver was certainly not enlarged, perhaps rather 
small; its surface was somewhat irregular, slightly and superficially fissured 
at points; no rounded nodules, however (as of cirrhosis), could be observed. 
On section, the tissue was (considering the decomposed state of all the organs) 
rather hard and dense, and seemed partially atrophied; its colour was deep- 
orange, and in some places there was an approach to "nutmeg" congestion. 

This case presents a well-marked example of the disease first described by 
Dr. Graves, of Dublin, and afterwards noticed by Sir Henry Marsh, Dr. Stokes, 
and other Irish physicians ; and whose true pathological character was, I be- 
lieve, first pointed out by me in a paper read to the Medico-Chirurgical Society 
of Edinburgh, in January, 1849, and subsequently published in the Monthly 
Journal of Medical Science. The affection has since been illustrated by Rom- 
berg and Henoch, and other German physicians, and has attracted the notice of 
some of our best writers on diseases of the eye. The history is interesting, as 
having occurred in a male, the cases on record, with few exceptions, having 
been seen in females. It is more particularly interesting as afi'ording an oppor- 
tunity of examining the morbid appearances after death, the only record of 
which that has yet appeared being that communicated to the Pathological So- 
ciety of Dublin by Sir H. Marsh, and by Basedow in Germany. In the case 
now related, as well as in that of a lady who had long laboured under this pe- 
culiar affection, and in whom it proved fatal also, by supervening pneumonia 
(the only instances which have occurred to myself of instituting post-mortem 
examinations), there exists a remarkable similarity in the chief morbid appear- 
ances with those described by Sir H. Marsh. These appearances chiefly con- 
sist in the very fluid state of the blood found in the heart and great vessels, in 
the dilatation of the cavities of the heart, and of the venous trunks, in the en- 
largement of the spleen and disease of the liver, and in serous efi'usion into the 
different cavities, the result of vascular obstruction. 



1855.] 



Ophthalmology. 



249 



Since the publication of the three cases related by me in 1849, 1 have, through 
the kindness of my professional brethren, seen many additional examples of 
this affection, a large proportion of which have gradually undergone a cure, 
while the remainder have benefited, or are now benefiting, by the use of iron, 
animal food, and fresh air. It is of great consequence to impress those suffer- 
ing from this affection with the belief of its curable nature, and to urge upon 
them the persistent employment of the means of restoring the red particles of 
the impoverished blood, and improving the general health ; for we have now 
examples before us to show that the neglect of these rules must lead, from 
functional disorder of the heart, to dilatation of its cavities, and to the usual 
train of consequences resulting from such a morbid change. 

The more extended our experience of the phenomena constituting this pe- 
culiar affection becomes, the more convinced shall we be that the point of de- 
parture from health is not in the heart itself, but in the impoverished condition 
of the blood, which, after a time, affects the heart and vessels functionally, and, 
by long continuance, involves them ultimately in fatal organic change. — Edin- 
hurgh Medical and SurgicalJournal, April, 1855. 

59. Affection of the Heart, Thyroid Gland, and Eyehalls. By Drs. Romberg 
and Henoch, of Berlin. — This disease, to which attention has been drawn by 
Marsh, Begbie, Cooper, &c., in Great Britain, seems also to be well known in 
Germany, and many examples of it have been observed by Pauli, Brueck, 
Basedow, and lastly by the authors whose interesting paper we have now be- 
fore us — Romberg and Henoch. Though differing in regard to the etiology of 
the disease as a whole, and disagreeing to a certain extent in the account 
given of the rise and occasion of its individual symptoms ; still, in the descrip- 
tions of all the writers now named, there exists so remarkable a uniformity, 
as to satisfy us of the identity of the disease which each has observed. 

We shall, in the first place, make our readers acquainted with some of the 
cases in an abridged form, and the remarks of Romberg and Henoch, and then 
add a few observations of our own, which the perusal of the former have called 
forth. 

Case 1. — A. S., aged fourteen, who had never menstruated, was treated, in 
the clinical ward, for anaemia, and cured by a preparation of iron. In October, 
1849, she again became a patient, her former disease having returned. At 
that time, the extraordinary paleness of her skin revealed her anaemic condi- 
tion. The right lobe of the thyroid was swollen, and the jugular vessels were 
seen pulsating. The anaemic sound was clearly audible in the neck. There 
Avas the evidence of an enlargement of the heart, and its first sound was at the 
base accompanied by a bellows murmur. The patient suffered from dyspnoea, 
increased by motion and from great weariness. The bowels were irregular. 
On the 12th November she was ordered to take iron, which, with a short inter- 
ruption, she continued to do till January, 1850. At that date, a decided im- 
provement in her whole system was visible. 

Case 2. — A girl of eighteen, who had first menstruated a year previously, 
began to complain of violent palpitation and uneasiness in the region of the 
heart, brought on chiefly by exertion, especially in ascending stairs. At the 
same time, a swelling had appeared in the front of the neck, and at times she 
expectorated blood. The diagnosis, after examination of the heart, was that 
something more than functional disorder existed, and that valvular disease was 
present. In this patient, as in the former one, the enlargement of the thyroid 
and the affection of the heart existed, but the eyes were not implicated. She 
differed from the former case in not presenting an anaemic appearance. 

Case 3. — Mrs. R., aged forty-seven, subject for many years to numerous 
hysterical complaints, was admitted inio the Clinic May 18, 1849. She com- 
plained especially of violent palpitation of the heart, and consequent agitation. 
During the attacks of palpitation she experienced a feeling of tightness in the 
throat, and a glimmering before the eyes. The thyroid was evidently enlarged, 
particularly in its right lobe, and in it she experienced a sense of pulsation and 
of pain during the occurrence of the palpitation. Then, also, the eyes became 
unusually large, and appeared starting from their sockets in such a manner as 



250 



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to expose her to the laughter of bystanders. The catamenia were regular, hut 
scanty. The pulsations of the heart were increased to 100 in the minute, but 
otherwise there was no change detected. She was hysterical, suffered from 
weariness and from irritability of temper, with inclination to weep. Although 
the symptoms had existed for nearly two years, they had considerably increased 
during the previous four months. In this patient the manifestation of anaemia 
was very clear. A mixture of digitalis, with phosphoric acid and valerian, 
were the remedial means employed, and amendment was so speedy that in July 
of the same year she was able to take a situation as lady's maid, and went to 
Dobberan, where she experienced great benefit from the use of the sea baths. 
In March, 1850, she was seen entirely freed from her former ailments. 

Case 4. — C. L., aged twenty, first menstruated at the age of thirteen, and 
suffered thereafter from complete amenorrhoea for a whole year. During this 
period she had a trifling swelling on the front of the neck. Menstruation again 
returned, but very irregularly, and the girl, from being blooming and robust, 
became pale and weak ; the thyroid swelling increased ; palpitation of the heart 
succeeded, and then followed a strange largeness of the eyes. Considerable 
benefit was obtained in this case from the steady use of iron. 

Case 5. — Mrs. B., aged twenty-five, presented herself at the Clinic on July 7, 
1848. Always healthy, and having regularly menstruated. She had for three 
weeks been occasionally exposed to a draught, when washing, with her neck 
uncovered. She had felt pain in the front of the neck, and had latterly noticed 
a slight swelling in the situation of the thyroid. On examination at the Clinic, 
the same remarkable prominence of the eyes as noticed in the other cases was 
observed, still the sight was not affected. Violent action of the heart existed ; 
and in the thyroidal tumour, now greatly increased, and very large, as also in 
the head, the pulsation was inordinate. The pulse was 144. Three cups of 
blood were taken, and in the following week leeches were applied to the en- 
larged thyroid : from these measures an evident, though temporary-, ameliora- 
tion followed, xlfterwards (early in 1850), from the use of digitalis, and due 
in great measure to the regular return of the menses, which had been much 
interrupted, restoration to sound health occurred. 

Case 6. — A. B., a young girl, aged seventeen, had suffered from violent pal- 
pitations for two years ; had also an attack of typhus fever, and had been 
neglected, owing to living in a country village. Was admitted into the Clinic 
November, 1847, when her appearance was most striking. The eyes were pro- 
truded ; the sight, however, unaffected. The thyroid was greatly enlarged, 
and appeared throbbing ; a loud systolic murmur was heard, and peculiar thrill 
felt over it. In this case, the occurrence of the palpitation was evidently fol- 
lowed by increase in the size of both thyroid and eyes. Pulse equal and regu- 
lar — 116. Bloodletting was adopted three times in the treatment of this case, 
and after a little time a leech was applied every fourth day to the enlarged 
thyroid ; as in the former case, a temporary benefit resulted. The girl appears 
to have ultimately fallen a victim to tubercular disease in the chest, surviving 
the time of her first illness for nearly three years. 

Taking the cases which have occurred in their own experience, and those 
which have been elsewhere recorded, there are in all twenty-seven which form 
the subject of the following interesting remarks by Drs. Romberg and Henoch. 
They acknowledge twenty-seven to be too small a number of observations to 
warrant any very decided opinions being drawn from them, but, at the same 
time, believe it sufiiciently large to afford the groundwork for much useful 
study. By far the larger number of the patients were females, only four of the 
twenty-seven were males. All with one exception were young, the most com- 
mon age being between twenty and thirty. In the larger number of the cases 
there existed the combination of the three symptoms of palpitation of the heart 
— enlargement of the thyroid and prominence of the eyes ; while in six of the 
twenty-seven cases one or other of the three was absent. In the two cases first 
treated by Dr. Romberg in the Clinic, the prominence of the eyes was not ob- 
servable. Undoubtedly of these phenomena the palpitation of the heart is the 
one best understood, and corresponds most readily with the view taken of the 



1855.] 



Olphthalmology. 



251 



■whole disease. Almost always the cardiac symptoms are those first discovered 
and first complained of; then, after a longer or shorter period, the swelling in 
the neck commences, and the prominence of the eyes follows. Only a few of 
the recorded cases lead to the supposition that the three diseased appearances 
arose at about the same time, certainly in the fifth case treated in the Clinic 
the enlarged thyroid was the first symptom noticed. It is well to inquire 
wherein the original afi'ection of the heart consists. That in some instances 
there exists organic disease is proved as well by examination during life as by 
yost-mortem examination (Basedow and Marsh) ; but, again, in others it is 
equally certain that the cardiac symptoms depend merely on an increased 
irritability of the organ (Cooper, Begbie, Lubarsch). Cases explicable on both 
these grounds, and on these only, have been treated by the Clinic. In regard 
to the thyroidal swelling, it is interesting to note its increase and subsidence 
after the violence of the cardiac palpitation — this fact is expressly stated by Sir 
Henry Marsh, and mentioned by Begbie as existing in his third case, and also 
noticeable at times in the fourth ; this, of course, points to an intimate relation 
between the two symptoms. Marsh and Heusinger describe the condition of 
the thyroid as a true hypertrophy, and it has been noticed by Graves that, after 
the lapse of years, the consistence of the gland has been much increased. 

As regards the remarkable prominence of the eyes, this symptom comes on 
gradually, and so far as vision is concerned it is not of much importance, see- 
ing that only in one case (Lubarsch) was it at all seriously impaired; but, 
though sight is not much afi'ected, the prominence of the eyes produces a singu- 
lar disfigurement, causing the sufferer to be not unfrequently avoided in com- 
pany. Acknowledging the great difficulty of determining upon what peculiar 
condition the prominence of the eyes depends, our authors set aside the view 
of the increase of the aqueous humour causing a true enlargement of the eye 
(Begbie — the theory also adoptea by Dr. Stokes), also that which attempts a 
solution by reference to an hypertrophy of the post-ocular cellular tissue (Base- 
dow). They look upon the idea of the prominence being due to a want of tone 
in the ocular muscles, and an accompanying congestion in the posterior parts 
of the eye (Cooper, Dalryraple) as more likely; but they appear to think still 
more favourably of the view of Heusinger, who found in two cases an extraor- 
dinary accumulation of fat in the cellular tissue behind the eyes, and regards it 
as the probable cause of the exophthalmos. 

Again, regarding the disease as a whole, our authors proceed to remark that 
certainly the larger number of the individuals so affected exhibited evident 
symptoms of anaemia, such as a remarkable paleness of the skin, the peculiar 
sound audible in the bloodvessels of the neck ; headaches often very violent ; 
giddiness, especially when in the upright posture ; humming sound in the ears ; 
attacks of fainting ; small frequent pulse, &c. Irregularity of the catamenia 
also is commonly present, while fluor albus, and sometimes complete amenor- 
rhoea, have been found. Symptoms of an hysterical nature further distin- 
guished not a few of the cases, the globus hystericus, neuralgic pains in different 
parts, coldness of the extremities, and strange wanderings of the mind. Base- 
dow describes a remarkable calmness and a great desire for pleasure as 
characteristic features of the mental condition. In some of the cases it is 
clear that if the disease was not originated, at all events it was furthered 
by the occurrence of a severe hemorrhage or flux, which reduced the system 
(Begbie) ; also a depressed state of both body and mind seemed connected 
with its first occurrence (Graves). But though anaemia was present in a 
large number of the cases, there are others whose commencement could not 
be traced to it, and anaemia cannot therefore be regarded as an essential 
requisite towards the explanation of the complex phenomena. The irregu- 
larity in the uterine system, too, cannot be regarded as altogether explanatory 
of the disease ; for, independently of males being subject to it, these uterine 
derangements, though marked, were of very varying nature. Heusinger directs 
attention to the condition of the spleen, which he found after death much in- 
creased in volume and manifestly diseased. — Edinburgh Med. and Surg. Journ., 
April, 1855, from Klinisclie Wahrneliimingen und Beobachiungen. 



252 



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[July 



60. Change of Colour of the Iris independent of Inflammation of its Texture. — 
It is a familiar fact, that one of the ordinary results of inflammation of the iris 
is a conspicuous change both in its colour and texture. But it is not so gene- 
rally known. Dr. Robt. Taylor states {Med. Times and Gaz., March 17, 1855) 
that "the colour may be completely changed, loithout any indication of diseased 
action in its texture," and he gives the following cases as examples of this. 

Case 1. — The first is that of a lady, who received an accidental blow on the 
right side of the forehead, nearly twelve months ago, in consequence of which 
% the sight of the corresponding eye failed slowly and painlessly, until, when she 

consulted me a short time siDce, she was unable to read the largest print. 
There was a deep-seated, mottled opacity, situated, apparently, in the posterior 
capsule of the lens. The veins from the interior of the globe were enlarged 
and tortuous, and the point of exit of one or two of them was tinged by a slight 
deposit of pigment; but this increased vascularity was equally conspicuous in 
the other eye, the vision of which was unimpaired. About six weeks ago, or 
ten months after the accident, she observed the first indications of change in 
the colour of the iris. It had formerly, like that of the left eye, been of a dark 
brown colour; it is now of a bright blue-gray, without the slightest admixture 
of brown, and presents a striking contrast to the dark hue of the other. The 
change was completed in four weeks. 

Case 2. — The patient, a woman, 29 years of age, is still under my care at the 
Central London Ophthalmic Hospital, for deep-seated disease of the right eye, 
identical, I believe, with the affection described by Dr. Mackenzie in the last 
edition of his work on Diseases of the Eye, as Retinitis Lactantium. When she 
commenced her attendance at the Hospital, vision was so far destroyed that 
she could scarcely distinguish between light and darkness ; but it has since 
been completely restored. 

Five weeks ago, the change in the appearance of the iris was first observed 
by her friends. Formerly, like that of the left eye, it was of a deep brown 
colour, mottled by a few minute specks of gray ; within the time specified, 
these specks have gradually enlarged, until their conjoined area now occupies 
nearly one-half of the iris, to the exclusion of the original dark hue. The 
change is still in progress. 

Case 3. — The third instance was observed in a man, who presented himself, 
on one occasion only, at the hospital, on account of capsulo-lenticular cataract 
of the right eye. I was at once struck with the difference in colour of the 
irides. That of the left eye was dark hazel, the gray being in minute specks, 
and in very small proportion to the brown; that of the right, in which the dis- 
ease existed, was bright blue-gray, with only a very few minute brown dots. 
He was very deficient in intelligence, and could not give any clear account of 
the length of time the difference had existed ; but it was too striking to admit 
of the possibility of its having been congenital, or even of very long continu- 
ance ; as in such a case he could not have failed to have heard it constantly 
remarked upon. 

In each of these instances the surface of the iris retained its brilliancy ; the 
superficial fibres were as sharply and clearly defined as in the unaffected eye; 
the pupil was free from adhesions, and dilated actively and fully under the in- 
fluence of atropine. Had the progress of the change not been observed, at 
least in the first two cases, it would at once have been concluded that the dif- 
ference in colour was congenital. 

My colleague, Mr. Haynes Walton, informs me that he has witnessed one 
example of a similar nature in connection with capsulo-lenticular cataract, and 
another in which a gray iris was permanently stained with rust-coloured spots. 
In the latter instance, however, there is reason to believe that the eye had 
suffered from syphilitic iritis. 

[The change of colour of the iris in these cases must have certainly resulted 
from some derangement of the nutritive functions of the part, and though this 
may not have been of an inflammatory character, it certainly was an abnormal 
action, it can scarcely be said not to have been a " diseased" one.] 



1855.] 



Ophthalmology. 



253 



61. Diphtheritic Conjunctivitis, and tJie application of Caustic in acute Injlam- 
matioti. By Dr. A. von Graefe. — The occurrence of fibrinous exudations upon 
the conjunctiva has been lung known. They difi'er from layers of coherent 
mucus in being more adherent, elastic, apt to coil up, and capable of splitting 
into fibres. Under the microscope they are seen to consist of coagulated fibrin ; 
the latter are composed of a convolution of young cells. 

The exudation first appears as a jelly-like coagulated substance. In the 
latter stages, it disappears before the increasing number of pus corpuscles. If 
in a case of acute conjunctivitis the upper lid be everted for a few minutes, the 
mucous membrane exposed to the air will be forthwith covered by such a layer. 
In very young infants, the blood is not sufficiently formed that it may yield a 
firm layer of fibrin ; at least, such an occurrence is the exception. 

The characteristics of this form of disease depend less on the exudation of 
fibrin than on the condition of the mucous membrane itself. In blennorrhagic 
inflammation, the conjunctiva is looser, succulent, and infiltrated by a fluid 
exudation. In diphtheritic inflammation it is stiff, and filled with a firm sub- 
stance. The eyelid is therefore prominent and immovable, instead of being 
only swollen and soft. In blennorrhoea the conjunctiva is very vascular, and 
the circulation is so far free that the greater number of the vessels contain 
fluid noncoagulated blood. The diphtheritic conjunctiva is, in consequence of 
a high degree of stasis of the blood, but sparingly supplied with the circulating 
fluid. The blennorrhagic secretion consists of yellow-coloured homogeneous 
pus ; that of diphtheritis is brownish gray and semi-transparent. In this latter 
disease there is a great sensation of heat experienced by the patient. 

The symptoms occurs as follow: In an eye previously sound, there sud- 
denly comes on swelling of the upper lid, attended by an increased flow of 
tears, and by a marked sense cf heat. The integument of the lid loses its 
folds, and becomes smooth and glistening. There is also incipient chemosis ; 
but the conjunctiva is not very red; the network of vessels forming large 
meshes ; the membrane between them being of yellow colour, studded with 
red points. The upper lid is remarkably stifi" ; its eversion is attended with 
both pain and difficulty. The appearance of the conjunctiva palpebrarum 
would not strike the inexperienced observer; but the smooth yellow surface is 
not in truth the membrane ; it is a thick layer of fibrin, which arrests the circu- 
lation in the part, and threatens destruction to the eye. 

After a time the lids lose their stiffness ; the conjunctiva becomes more 
spongy and looser; the fibrin separates; the vessels fill, and pour forth dis- 
charge ; the chemosis loses its yellow colour, and the peculiarities of the 
diphtheritis are lost. The duration of the different stages varies extremely. 
The author has seen the stage of fibrinous exudation last from six to ten days ; 
that of succulence and spongy alteration of the mucous membrane coming on 
afterwards. But this latter may be complicated by relapses of the exudative 
inflammation. 

The dangers of diphtheritic inflammation are those which refer to the cornea. 
A part becomes turbid, and loses its epithelium ; the colour changes to a muddy 
yellow; a sore or ulcer forms, which becomes deeper and deeper; while upon 
its surface, by the aid of a magnifying glass, numerous points are seen, which 
indicate molecular necrosis. 

It is mostly an epidemic, may proceed from a variety of causes, and is de- 
cidedly contagious. The prognosis is worse in adults than in children. Of 40 
young patients suffering from this disease, the eye was lost in nine cases. 
Three had leucoma, with adherent iris ; 21 recovered without any affection of 
the cornea; 7 had slight corneal affections at later periods. 

As regards treatment, the author recommends abstraction of blood, the ap- 
plication of ice, and the administration of mercury. He, however, attaches 
especial importance to the application of caustic. He affirms that this method 
of treatment is not only permissible, but is indicated in all forms, and from the 
commencement; that it controls the worst and most dangerous changes ; that 
ulcerations of the cornea do not contra-indicate its use. For the acute forms 
he uses a solution of ten grains nitrate silver to the ounce of water, or a solid 
stick of nitrate of silver and nitrate of potash fused together. The caustic 
No. LIX.—JuLY 1855. 17 



254 



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[July 



must be applied to all the diseased surface, and must be proportioned to the 
severity of the attack. — Med. Times and Gaz., 17th Feb., 1855, from ArcJiivfiXr 
Oplithalmologie. 

62. Trephining the Os Unguis for Fistula Lachrymalis. — M. Demarquay, of 
Paris, has revived this operation, which he claims as new^ and takes credit to 
himself for devising it. What is more remarkable, the English Journals give 
it as a novelty without comment, and thus sanction the claim. 

The operation was performed by Mr. Pott, who used a trocar for the pur- 
pose, and by Mr. Hunter, who had constructed an instrument like a shoe- 
maker's punch, by which a circular piece of bone could be cut out completely. 
The late Dr. Physick used to mention the operation in his lectures, and we are 
under the impression that he performed it in a few cases. Like most French 
discoveries in ophthalmic surgery, it is an old practice long since abandoned. 



MIDWIFERY. 

63. Case of Presentation of the Bladder in Labour. By Alex. Harvey, M. D. 

— Mrs. M , 93t. 28, was taken in labour of her firs* child on the evening of 

Tuesday, the 4th July last, some weeks before the expected time of her de- 
livery. She sent for me the same evening, when I found her complaining of 
pains in the lower part of the abdomen, both behind and in front, and likewise 
round the hips. She had an opiate given her, which had the effect of relieving, 
indeed, of removing the pains, and procuring for her a comfortable night's rest. 

The pains returned next morning. On examining her per vaginam, the os 
uteri was found slightly dilated. In the evening the pains had become more 
decided and regular, and the os uteri more fully dilated. No bag of waters 
could be discovered, and the patient was not aware of its having broken. The 
presentation was ascertained negatively. It was not the head, but its real 
nature remained doubtful. 

At 3 A. M. of the following day, the os uteri was pretty fully dilated, and 
the pains were good. The presentation, however, was still uncertain. It 
seemed impossible to doubt that what had all the characters of feet could be 
aught else ; but the limbs connected with them, besides being themselves ex- 
tremely small and tiny, ended in what seemed certainly not a breech, and 
very exactly resembled the shoulder. No anus could be felt, nor organs of 
generation. The limbs were brought down, and proved to be the feet and 
lower extremities. 

The pains continued vigorous, but the child descended very slowly till about 
1 o'clock in the afternoon, after which the labour advanced steadily, although 
still very slowly, till about 3 o'clock, when the entire foetus was expelled by 
one strong pain. 

Altogether, the labour occupied above thirty-six hours. 

For some time before the delivery of the woman, and after the full dilatation 
of the OS uteri, the presentation was as follows : The front of the child was to 
the spine of the mother ; the trochanters and head of the thigh bones, which 
were in connection with a bony surface of very limited extent, and (as before 
observed) very closely resembling the top of the shoulder, lay behind the pubis. 
Filling the hollow of the sacrum was the front of the abdomen, lying remark- 
ably low down and pressing on the perineum, occupying besides, to a great 
extent, the cavity of the pelvis. 

At the moment of delivery, and for some time previous to this, this abdomi- 
nal mass, in the form and shape of a large round swelling, which was tense, 
plastic, and unyielding, filled up the whole outlet ; the breech, or what ap- 
peared to be the breech, being pushed upwards behind the pubis. The mass 
in question passed through with extreme difficulty, and with corresponding 
anguish to the mother. 



1855.] 



Midwifery, 



255 



The child was stillborn. On examining it, it was found that there were no 
buttocks, and that the bony pelvis was but imperfectly developed, small and 
insignificant. There was no anus, nor any trace of one. A projecting fold of 
skin of a livid colour occupied the site of the scrotum or labia, and had a shal- 
low imperforate fissure in the centre of it. 

The abdomen (speaking comparatively) was of enormous size, and was dis- 
tended by what was manifestly fluid in its interior. It encroached upwards on 
the chest, which was preternaturally short and narrow. The child's neck was 
apparently wanting, and the head was small, elongated, and livid, but not 
otherwise abnormal. 

The general surface presented marks of incipient decomposition. 

On laying open the abdomen, the urinary bladder was found occupying the 
greater part of its cavity. It formed a round or oval tumour, considerably 
larger than the average size of the foetal head. Unfortunately, it was acci- 
dentally punctured, and its contents escaping, neither the real nature nor the 
exact amount of the fluid it contained could be ascertained; but it had the 
colour and odour of urine ; and, judging as well from the apparent capacity of 
the bladder as from what was seen to escape, the fluid might have amounted 
to about a pint and a half 

The bladder had no outlet, but the ureters entered it in the usual way, and 
were pervious throughout. Moreover, the rectum also opened into it, but no 
indications of the presence of meconium were discovered in the bladder. The 
condition of the generative organs was not minutely inquired into ; but, on a 
cursory examination, none could be seen, and the sex of the infant was not 
made out. 

The striking feature in this case was the extreme difficulty with which the 
delivery was accomplished, a circumstance now manifestly referable to the un- 
yielding nature of the fluid in the urinary bladder, which was actually the 
presenting part, and which, from the action of the uterus upon it, had to make 
its way by its broadest possible diameter. — Edinburgh Med. and Surg. Journ., 
April, 1855. 

64. Abnormal QuantiUj of Liquor Amnii. — Dr. James A. Sidet related the 
following examples of this at a recent meeting of the Edinburgh Obstetrical 
Society : — 

Case I. — Mrs. B., Stevenlaw's Close, pregnant of her third child, when I saw 
her in December, 1852, with Dr. Aiken. She said she was six months gone ; 
at that time she was as large as other women at full time. The os uteri was 
open to about the size of a shilling ; the foetal pulse could not be heard, al- 
though examined several times. On the 1st January, 1853, I was sent for, and 
found her in labour; the abdomen was extremely large, but not pendulous, and 
the parietes so thin that distinct fluctuation could be felt. I left her, and was 
again sent for on the morning of the 2d, about 5 o'clock, when I found the os 
uteri nearly fully dilated, and the pains very rapid and strong, but not the 
slightest effect produced on the bag of waters, which was tightly stretched across 
the OS. Believing that there was superabundance of liquor amnii, and over dis- 
tension of uterus, I gave her a dose of ergot, had her brought to the edge of 
the bed, and ruptured the membranes with a quill, when about four gallons 
and a 7m//' of liquor amnii were caught in basins, and a great quantity besides 
flowed on the bed and over the floor. The child, evidently about the seventh 
month, w^as soon born, but dead; had been so for some days ; placenta came 
away of itself. Uterus contracted well, and no hemorrhage followed. Woman 
made a good recovery. 

Case 2. — Mrs. McK., Richmond Street, abdomen pendulous, pregnant of third 
child, at full time. Said she was much larger than on previous occasions, and 
thought she would have twins. 

Nov. 19, 1854, 10 A. M. Labour was tedious during the first stage, from in- 
durated OS from ulcerations ; but got great benefit from venes. and tart. ant. and 
a bandage. The os uteri at length was fully dilated, but after that the pains 
made no progress ; membranes were never pressed down. I had her brought 
to the edge of the bed, and caught in basins three gallons of liquor amnii, a 



256 



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[July 



good quantity flowing on the bed and floor; the child was born about two hours 
after; woman and child did well. — Monthly Journ. Med. Sci., April, 1855, 

65. Cases of Placenta Prcevia. — The following cases of placenta prasvia were 
communicated to the East Kent and Canterbury Medical Society, during the 
sessions 1852-55. 

Mr. F. F. GiRAUD was summoned about a month before the full term of preg- 
nancy to attend the wife of a tradesman in Faversham, who had already given 
l)irth to nine children, on account of slight hemorrhage having occurred from 
the womb during the act of relieving the bowels. He could not determine by 
examination whether the placenta was over the os uteri, from that part being 
too much closed, and too far back to admit the finger. As she was habitually 
costive, and had been straining at the water-closet when the hemorrhage came 
on, he thought it possible that the blood might have escaped from a congested 
state of the vessels within the vagina ; and, after having emptied the bowels 
with castor oil, he desired her to be more attentive to the state of her bowels. 
No more hemorrhage ensued until the 28th February, exactly a month from 
its first occurrence. The patient then again perceived a discharge of blood on 
relieving the bowels ; on looking into the night-stool, he found a small coagu- 
lum, together with a very ofiensive motion. She felt slightly faint, which Mr. 
Giraud attributed to alarm more than to the loss of blood; the pulse being 
firm, and no hemorrhage continuing. There were no indications of approach- 
ing labour, and the os uteri would scarcely admit the end of the finger, and 
not sufficiently to ascertain the state of the parts within. Under these circum- 
stances, he gave the patient a little castor oil, and directed the nurse, if the 
slightest return of bleeding should take place, to send to him immediately, as 
it might be necessary to have recourse to artificial delivery. In about four 
hours, an alarming message was sent; and in a few minutes Mr. Giraud was 
at the bedside of the patient, where he also found his partner, Mr. Garraway. 
It appeared that, on using the night-stool, an enormous quantity of blood had 
passed away ; and her nurse, finding her very faint, had some difficulty in get- 
ting her into the bed. lie immediately passed his hand into the vagina, and 
had great difficulty in overcoming the resistance of the os uteri. The placenta 
was completely over the mouth of the womb ; but in his eagerness to accom- 
plish the delivery, he was not aware whether his hand passed through any 
part of it or by its side. The pressure of the fingers easily ruptured the mem- 
branes ; Mr. Giraud obtained firm hold of the feet of the child, and extracted 
it without any material difficulty, in about a quarter of an hour from the first 
introduction of the hand into the vagina. During this process, he was not 
aware of any hemorrhage going on ; but the patient became very faint as soon 
as it was over, the pulse small and feeble, her breathing short, and, in spite of 
brandy, ether, and ammonia, she expired within half an hour of the birth of 
her child. 

Remarks. — The unusual circumstances attending this case were these: 1. 
The hemorrhage occurred each time during the action of the bowels, ceasing 
altogether when that effort was over. 2. The second attack of bleeding at the 
full period of gestation was so profuse as to sink the patient irrevocably, al- 
though no time was lost in the delivery of the child, and the first bleeding on 
the same day was of small amount. 3. In the sixty-two cases of placental 
prescnsation, recorded by Dr. Robert Lee, in his Clinical Midwifery, the bleed- 
ing, for the most part, came on in repeated gushes, and when recurring at the 
full period of gestation, each sudden and considerable escape of blood was 
more or less followed by continuous hemorrhage of less moment, but which 
was not the case in this instance. This was only the fourth case of placenta 
proavia which had happened in Mr. Giraud's practice during a period of twenty- 
seven years. The three former terminated favourably under the usual treat- 
ment, viz : introducing the hand and delivering the child. 

iSIr. RiGDEN reported four cases of placenta praevia. which had occurred in 
his own practice. The first happened in January, 1842, in the mother of 
several children, who was advanced to the eighth month of her pregnancy. 
The vertex of the child presented and pressed upon the placenta, which was 



1855.] 



Midwifery. 



257 



thus expanded over it. An opening was made in the placenta, and the dead 
child was expelled through it. The mother recovered well. The second oc- 
curred in November, 1844; the mother was about six months and a half 
advanced in pregnancy ; the child was delivered by turning, and was still- 
born. The mother rallied at the time, but died from puerperal peritonitis, six 
days after delivery. The third took place in March, 1846, and was also at the 
period of six months and a half. Delivery was effected by turning, and the 
child was stillborn. The mother recovered, but suffered from neuralgic pain 
in one leg for several months. In the fourth case, April, 1847, a stillborn 
child was delivered by turning, at six months and a half ; the mother recovered. 

Mr. Reid related a case which had been under his care in October, 1848 ; 
the patient was the mother of eleven children. During the two months pre- 
ceding the full period of pregnancy, there had been, at intervals, several con- 
siderable losses of blood. When first seen, the patient was prostrated by a 
profuse hemorrhage which had taken place suddenly. The vagina was imme- 
diately plugged, and stimulants were freely administered ; after a time the 
hand was introduced, and the placenta, which was directly over the os uteri, 
was detached by the fingers, the os not being sufficiently dilated to admit the 
hand. After this, the prostration of strength became so great, although there 
was no further hemorrhage, that for three hours it was necessary to give the 
whole attention to the restoration of the patient's vital powers. During the 
whole of this period no contraction of the uterus was perceived ; though at 
last, when the hand was introduced, the placenta was found projecting in the 
form of a cone through the os uteri ; by gentle traction, which excited slight 
uterine pains, it was removed. After waiting some time, and apparently no 
effort being made by the uterus to expel the child, the head, which presented, 
was perforated, and the child was delivered. Uterine pains returned with the 
traction that was used, and the uterus contracted firmly after the child was 
withdrawn ; the patient subsequently had a slow but good recovery. As far 
as one case could, this confirmed the rule which Dr. Murphy had established 
in considering the alternative of separating the placenta or turning, in cases 
of placenta prsevia ; that, in instances of extreme exhaustion, the plan of sepa- 
rating the placenta was not only advisable, but would be found a valuable 
mode of treatment. In this case there was the greatest probability that any 
forcible introduction of the hand, in order to turn, would have proved fatal. — 
Assoc, Med. Joiirn., Feb. 9, 1855. 

66. State of the Foetal Pulse as an Indication for Artificial Delivery. — Professor 
Simpson made some remarks at a recent meeting of the Edinburgh Obstetrical 
Society on the indications afforded by the stethoscope for expediting deliver^'-, 
and specially directed the attention of the Society to the fact that, while danger 
was usually indicated to the mother during labour by the increased rapidity of 
her pulse, the death of the child was most frequently threatened when the foetal 
pulse became slower and slower. It was known that in cases where, during 
labour, pressure was exercised upon the cord, the pulsations of the foetal heart 
became feebler, and were at length suspended by the continuous pressure. 
This was most probably the way in which the foetus perished during severe 
and prolonged labours ; the aeration of the blood by the placenta being imper- 
fect, or entirely suspended. There were, however, cases in which danger was 
indicated to the child by the foetal pulse becoming much more rapid than or- 
dinary, reaching 150 or 160 beats in the minute, and at the same time very 
irregular. Dr. S. believed the danger in these cases did not result from pres- 
sure on the umbilical cord, as in the cases where the pulsations became slower 
and slower, but from pressure, or some source of irritation acting on the brain. 
— Monthly Journ. Med. Sci., April, 1855. 

67. Epidemic Puerperal Fever which recently prevailed in the Publin Lying-in 
Hospital. — Dr. McClintock read before the Dublin Obstetrical Society, March 
2, 1855, the following interesting account of this epidemic : — 

" The epidemic, whose history I am about to bring forward, unequivocally 
declared itself in the first week of last December [1854], and subsided in the 



258 



Progress of the Medical Sciences. 



[July 



middle of February [1855]. Unlike the one of 1845, its outbreak cannot be 
said to have been either sudden or unexpected, inasmuch as twelve or fourteen, 
cases of puerperal peritonitis and phlebitis, together v^^ith a fevt^ isolated exam- 
ples of typhus and scarlatina, had occurred in the house during the preceding 
nine months. 

" From the beginning of December to the 14th February, 182 women were 
confined in the hospital. This, I may just remark, is not half the average 
number of deliveries in the same period, and was owing to a stop having been 
put, in the latter part of December, and during all January, to the admission 
of patients, except such as were so near delivery that it would have been 
attended with imminent risk to send them away. 

"Now, of these 182 women, 38 — that is, 1 in every 5 — were unequivocally 
affected with the symptoms of the disease ; and out of these 38 so affected, it 
recovered, and 21 died, making the proportion of fatalities nearly 1 in 8 of all 
admitted ; a frightful rate of mortality, and more than tenfold the average of 
this hospital. 

" In three of the above cases, the puerperal disease was complicated with 
scarlatina. Two of these died, and the third made an excellent recovery, 
though the metritic attack was a marked one, and the scarlatina very severe, 
showing itself so early as the second day after delivery, and presenting in its 
course a truly formidable array of symptoms. On two occasions, this woman 
seemed to owe her preservation solely to the liberal exhibition of wine and 
brandy, and this too at the very time when we had every reason to fear the 
existence of uterine inflammation. 

" It would be wearisome and tedious were I to give the individual history of 
all these cases, and yet I am quite at a loss how to classify or arrange them, 
not knowing what to take as the basis of any such classification, as they pre- 
sented considerable variety in their symptoms, course, and morbid appear- 
ances. For example, in many cases, including some of the most malignant, 
there was no initiatory rigour whatsoever. Again, intense abdominal pain 
was a prominent feature of some cases from the onset to the termination ; 
whilst in others, equally fatal, there was no complaint of the belly. Vomiting, 
likewise, was an early and constant attendant upon the disease in not a few 
instances, whilst in some it did not appear at all, or only at the close. And so 
on with the morbid appearances ; some cases presenting intense peritonitis, 
others phlebitis, and a few putrescence of the uterus, and these either sepa- 
rately or conjointly. There were two features, however, common to them all, 
namely, a very rapid circulation, the pulse ranging from 120 to 140, and a 
marked adynamic type ; so marked, indeed, that in two cases only did I feel 
justified in making trial of phlebotomy, and these, as you may suppose, were 
selected cases. Yet, in each of them, the supervention of syncope rendered it 
necessary to discontinue the bleeding before ten ounces of blood had been ab- 
stracted, one losing about seven, and the other nine fluidounces ; and what is 
still more worthy of attention is the fact that in neither of these instances did 
the blood exhibit, after some hours' standing, any of the characters indicative 
of inflammation. Both these patients died. 

"In nothing did the various cases differ so much as the manner in which 
the disease made its invasion. In the majority, a rigour announced its first 
onset, this being speedily followed by pain or uneasiness in the uterus ; except 
in three or four instances, the pain was not by any means intolerable or severe 
at the commencement, or even for some hours afterwards. Tenderness of the. 
uterus to pressure, however, with perceptible augmentation of its bulb, was 
almost invariably found to be present from an early period of each case. 

" The first approaches of the disease, when not ushered in by rigour, were 
sometimes remarkably slow and insidious — the only deviations from normal 
convalescence being a trivial acceleration of the pulse and a slightly furred 
state of the tongue, with, perhaps, diminished secretion of milk. On two or 
three occasions the attack began apparently with after-pains, or at least with 
pains of an intermitting character, commencing almost immediately after de- 
livery, and so equivocal in their nature that it was impossible to say when 
they ceased to be purely spasmodic and became inflammatory. Mr. Hey, of 



1855.] 



Midwifery. 



259 



Leeds, in his Treatise on Puerperal Fever, makes the remark ' that, during the 
epidemic season, lying-in women were unusually subject to after-pains, and 
those of a more violent kind than ordinary/ My recent experience is quite in 
accordance with this observation. 

'* The patient's own representation of her state we found could not always 
be relied on, owing to her unconsciousness of the presence or the progress of 
the malady. Frequently her statements on this head, though made with confi- 
dence and complacency, were yet so utterly at variance with the symptoms 
and actual condition of the patient, that the most inexperienced observer could 
scarcely have been deceived by them for one moment. Whether this apparent 
ignorance of her real state arose from an unwillingness to believe she was 
affected with illness, or formed part of the disorder, I cannot take upon me to 
say ; but certain it is that no less than four or five of these poor creatures have 
assured me, in language of gratitude and self-satisfaction, that they felt per- 
fectly well, and this too when their general symptoms plainly forbade all hope 
of recovery. 

" This complete unconsciousness of danger, however remote, at a time when 
the hand of death was almost upon the patient, was a curious and distressing 
feature of the disease ; and is the more remarkable from the fact that these 
women were apparently in full and perfect possession of their mental faculties. 
I have once or twice before observed the same in women dying of pure metro- 
phlebitis. 

" Vomiting was not by any means a very prominent or constant symptom, 
except in the marked peritonitic cases ; though in nearly all the fatal cases it 
came on some hours before death. Several of those who recovered had sick- 
ness of stomach, and a few of them even vomited large quantities of the dark- 
green tenacious fluid which has been aptly compared to green paint. 

"Guided by the experience of this epidemic, I feel disposed to regard the 
state of the tongue as a more reliable prognostic than any other single symp- 
tom. With only one or two partial exceptions, I never saw a patient recover 
when the tongue had become dry, or brown, or glazed ; I have observed this 
symptom before any of the others had assumed a mortal or even threatening 
character ; nor was it absent in any of the fatal cases of the disease. 

*' At the outset of an attack the tongue was usually white, slightly furred, 
and somewhat less moist than natural. In many cases, this state of the organ 
has been the very first symptom to excite alarm, and to apprise us of the com- 
ing storm. 

" As the disease made progress, the next unfavourable change observed in 
the state of the tongue was a dry, brownish streak down its centre, and more 
remarkable towards the base. This condition gradually extended until the 
entire dorsal surface of the organ was involved. 

"I think I am justified in asserting that the prevailing character of the 
tongue in the late epidemic was a close approximation to what is usually called 
the ' typhoid tongue,' and this is one symptom wherein it difi'ered from the 
epidemic of 1845, in which the tongue presented most usually a broad, soft, 
creamy appearance. Mr. Hey, in his Account of the Puerperal Fever as it visited 
Leeds, makes the following remarks, which are pertinent to our present sub- 
ject, as marking the contrast, in this symptom, between the two epidemics : — 

" 'The tongue was never incrusted with the dry brown fur of typhus, except 
the disease was of long continuance, or had been improperly treated. It was 
generally moist and soft, and though it was not unfrequently covered with a 
thick white or brownish fur, yet it was often hut little altered from its natural 
appearance to the last, even in bad cases.' 

" Diarrhoea was present in most of our cases, but was not so conspicuous or 
so formidable a complication as in the epidemic of 1845. I cannot but think 
that its first production was often attributable to the mercury and some of the 
other remedies which were used to subdue the disease ; had it been otherwise, 
it is probable we should have experienced more difficulty in restraining it. 

" Fulness of the belly, with tympanitis to a greater or less extent, was almost 
universal ; but in the individual cases this condition did not become remark- 
able till an advanced stage of the complaint, except in those which showed 



260 



Progress of the Medical Sciences. 



[July 



from an early period a preponderance of the symptoms referable to inflamma- 
tion of the peritoneum. 

" The extreme rarity of cerebral disturbance in the course of puerperal fever 
is attested by nearly all observers, and the general tenor of my own experience 
agrees therewith. Nevertheless, I saw four cases which were exceptions to this 
rule. Two women, some hours after the first appearance of the disease, be- 
came quite lethargic, insomuch that it was only with great difficulty they could 
be roused to any degree of consciousness ; and in this state, closely bordering 
on coma, they remained till their death, not many hours after. Another pa- 
tient was affected in quite an opposite way. She was very restless and excited, 
wanting to get out of bed, and with difficulty restrained from doing so. Along 
■with this she had a kind of noisy delirium, bearing a very close resemblance to 
one form of puerperal mania. These three women exhibited in a marked de- 
gree the same morbid appearance, namely, putrescence of the interior of the 
uterus and sloughing of the vagina. The fourth patient actually became ma- 
niacal three or four days after the development of puerperal fever. In the 
course of a week, however, she regained possession of her reason, but was very 
near dying of the puerperal fever. 

" There seemed to exist throughout the epidemic a strong tendency to putre- 
scence or sloughing of the uterus and vagina, and this, too, quite irrespective 
of the length or character of the labour. In six cases, we had direct proof of 
the existence of this gangrenous condition ; two of these were patients that 
recovered, and had sloughing of the vagina. 

"This constitutes an important feature in the late epidemic, and places it in 
strong contrast with the disease as it presented itself to Dr. Joseph Clarke 
and Dr. Collins ; for neither of these authors makes any mention of such having 
occurred in their experience. 

" Dr. Collins, in describing the morbid changes which he met with in the 
uterus, as a result of puerperal fever, thus expresses himself: ' The uterus, in 
the great majority, was quite natural in appearance ; in some it was soft and 
flabby ; and in a few, unhealthy matter was found in the sinuses.' 

" Elsewhere in his report he states that only one case of sloughing of the 
urethra occurred during his seven years' mastership. 

"Dr. Clarke, in his account of the epidemic of 1787-8, distinctly says that 
no unequivocal marks of putrescency in any part of the system appeared in the 
disease. 

" It has already been stated that in every instance the pulse was found to be 
very rapid. At the commencement of an attack it was rarely below 112, occa- 
sionally much higher; and as the symptoms became more developed, and the 
disease made progress, the pulse commonly rose to 130, 140, and even 160. 
The other characters of the pulse were sufficiently remarkable to render them 
deserving of notice. In no one instance could we liave applied to it the epithet 
' incompressible ;' on the contrary, it was invariably soft and yielding, and 
gave to the finger a sensation that is best described by calling it ' liquid or un- 
dulating.' 

" During the epidemic of 1845, and I believe in former epidemics also, tris- 
mus and convulsions prevailed to an unusual extent among the children born 
in the hospital. It is a fact, however, worth recording, that not a single ex- 
ample of either of these complaints presented itself during the entire period of 
the late visitation. 

"It rarely happens that puerperal fever breaks out in the hospital without 
its contemporary appearance in private practice ; and it never happens, I be- 
lieve, that it prevails to any extent outside of the hospital without appearing 
among the patients within its walls. On the late occasion, I had reason to 
know that several deaths had occurred from the disease amongst women con- 
fined at their own homes, and lacking neither comfort nor attention, before it 
visited the hospital. Nor since then were its ravages confined to the poor in- 
mates of our wards ; for many women among even the upper classes of society 
were carried off under its fatal influence. During the months of December and 
January, no less than twelve of such deaths, in and about Dublin, came to my 



1855.] 



Midwifery. 



261 



own knowledge; and I have heard of four or five more occurring in the begin- 
ning of last month. 

" On the outset of the fever in the hospital it displayed uncommon virulence, 
and the first seven patients who were attacked fell victims to its deadly ma- 
lignity. 

" It may not, perhaps, be uninteresting to mention the number attacked on 
different successive days, as marking, to a certain extent, the progress of the 
epidemic. Thus, on each of the following days, viz : the 1st, 3d, 4th, 6tb, 9th, 
10th, 11th, and 12th of December, there was one woman seized with the dis- 
order; three on the 13th ; and three on the 15th: on no subsequent day of this 
month was there more than one ; and on many days not one was attacked ; 
but in February ^li^o were attacked on the 8th ; two on the 9th ; and two on the 
10th. 

*' With respect to the period after delivery at which the patient was seized, 
the following are the general results : 2 were attacked in three hours from the 
completion of labour ; 1 in four hours ; 1 in twelve ; 1 in fourteen ; 1 in seven- 
teen ; and 1 in twenty-two hours. Each of these seven cases terminated fatally. 

" One was seized in twenty-two hours after delivery, and 1 in twenty-three ; 
the former recovered, and the latter died. Thus, we see, of 9 patients, in 
whom the complaint manifested itself on the first day of childbed, 8 died ; 12 
were affected on the second day, 6 of whom died ; 10 were attacked on the 
third day, and of this number the disease proved fatal to 3. 

*' One woman, who was slowly recovering from an attack of scarlatina, which 
eame on soon after delivery, was seized with symptoms of peritonitis on the 
tenth day, under which she rapidly sank. There are yet five cases to be ac- 
counted for, but in these we could not fix the precise day on which the disease 
attacked them, so stealthy and imperceptible were its incipient advances. 

"This low, insidious manner in which the disorder not unfrequently crept 
into the system (if I may so say), taking hold upon the vitals without giving 
any unequivocal evidence of its presence, constitutes, I think, a remarkable 
feature of the epidemic, and places it in strong contrast with the epidemics 
described by Grordon, Hey, Armstrong, Joseph Clarke, Collins, and others. 

Erom Dr. Collins's report of the hospital, it would appear that between 
one-third and one-fourth of all the patients admitted were primiparse, and this 
exactly corresponds with Dr. Hardy's and my report. But amongst the pa- 
tients attacked with puerperal fever, in the late epidemic, a much larger pro- 
portion than the above were confined of first children; in fact, 19, or one-half 
of the 38, had been pregnant for the first time. Curious to say, Dr. Collins's 
experience on this point is exactly the same as my own ; for, of his 88 cases of 
puerperal fever, 44, the one-half, we perceive, were women in their first 
labours. 

" Although I have not made it a matter of special statistical investigation, 
still I think I am correct in saying that those women who were in bad health, 
or suffering any chronic complaint at the time of admission, as well as those 
who had tedious or difficult labours, were more liable than others to become 
the subjects of puerperal fever. 

" Dr. .Joseph Clarke's experience upon this point agrees with mine. He 
observes: ' Most of our patients attacked in the year 1787 were admitted in a 
weakly state, or had tedious and fatiguing labours.' 

_ " With reference to the important and much debated question of the conta- 
giousness of puerperal fever, my late experience does not enable me to say 
anything decisive. Two facts, however, I may be permitted to mention as 
being, in some degree, relevant to this point. On four different occasions it 
happened that the two patients in adjoining beds were seized with the disor- 
der. I do not attach any weight to this circumstance myself, but think it right 
to mention it. 

" The other fact easily admits of being construed into a proof of the conta- 
gious nature of the disease. 

"In two opposite wards (Nos. 7 and 8), on the same corridor, there were 
nine fatal cases, nearly one-half of the entire number of fatalities, and more 
than occurred in any other three wards. Now, the only way in which I can 



262 



Progress of the 3Iedical Sciences. 



[July 



account for this is, that a mother and daughter are respectively the nurses of 
these two wards, and having, on this account, more intercommunication, 
would be very likely to convey infection from one ward to the other. 

" The duration of the disease in individual cases varied a good deal. One 
patient died in fifty hours from the period of invasion ; 1 in sixty hours ; and 
2 in seventy-two hours. These were our most rapid cases. Four or five days 
was the average length of time that patients lived after being seized with a 
fatal attack of the fever. 

" The influence of the seasons has been sometimes alluded to as a cause of 
childbed fever. In the MSmoires sur les Hopitaux de Paris, M. Tenon has given 
a series of tables exhibiting the number of births, and the mortality of lying-in 
women and children at the Hotel-Dieu, in the several months of each year of 
the decade from 1776 to 1786 inclusive. These statistics show December to be 
the most fatal month, and June, July, August, September, and October the 
least so. 

Of the mode of treatment pursued with the different patients who were 
attacked with the disease, I cannot here give a detailed account ; but a brief 
outline of the general principles on which it was conducted, and of the com- 
parative utility of the principal remedies employed, may prove not unaccept- 
able to the Society. 

" I believe it may with truth be affirmed that bleeding, in this epidemic, was 
inadmissible. The only cases in which it was tried proved it so, and both of 
them died, the disease seeming to be wholly unaffected, if not aggravated, by 
the measure. My opinion on this point is not in the least shaken by the dic- 
tum of Gordon, ' That puerperal fever is inflammatory at the commencement, 
and putrid only in its progress backed though it be by the experience of 
Hey, Armstrong, and Professor Meigs, the latest and most voluminous author 
on puerperal fever. Gordon himself states that, unless he could abstract 
twenty-four ounces of blood at the first depletion, he despaired of the patient's 
recovery ; and this very statement explains the secret of his success. His 
cases were nearly all examples of the sthenic, synochal, sporadic form of the 
disease, which, as we all know, is by far the most manageable form. But the 
cases which would not bear bleeding, and which, in other words, approached 
to the low typhoid puerperal fever that is chiefly met with in hospitals, he 
found to be the most intractable and the most fatal. We find Dr. Meigs, too, 
saying, * Very few persons can be expected to survive these childbed fever in- 
flammations, whether accidental or unavoidable, when the circumstances for- 
b